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I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES F,A <br /> Y FIA E NENVIRONMENTAL REALTH DIVISION r <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 �'�-� �.'� <br /> IP O BOX 2009, STOCKTON, CA 95201 r p r 2 Y 19,9?_ <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSU _ED : I``A0'III I ( If+I v <br /> • i+ ii 'tt Itf ` ti>trll I ; <br /> (Complete i11 Triplicate) <br /> IppliCaticon la hereby made to Ban Joaquin Cocrnty for a permit to construct and/or install the work herein described Thane <br /> application to made in corWliance with Soon If <br /> n Joaquin County Ordinance o 5119 and 1862 and the (Rules and Regu <br /> Joaquin County public Health Services <br /> f�10 Gv]41- 00 /� p�Or� l <br /> lob Address r , `� Crry ���G_�. Lot Ties/Acreage <br /> Q a s / { 00 �Lct ICdIG1CjrL�on�ZOr� �i�c- 9s <br /> wrier! Name r Add+ess , <br /> / UaI7 /_d<lE ace Pe.¢���� C 617 �f one CS/o�46 Z -S/ O <br /> Address <br /> onlracter - 1f� License o <br /> YPE OF WELL/PUMP NEW WELL . /illi/-¢ WELL REPLACEMENT 1-1 DESTRUCTION C1 Out or service cell 0 <br /> Monitoring Well <br /> PUMP INSTALLATION p 121 1 SYS( Ili REPAIR 0 5.�� OTHER (fI �, 41OR/^/4 09 <br /> (STANCE TO NEAREST SEPTIC TANK SEWER LINES 1'$fP &SP0SAL FLD �PROP tINE <br /> FOUNDATION AGRICULTURE WELL � OTHER WELL!Sa r °`PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROSLFM AREA CONSTRUCTION SPECIFICATIONS `7 <br /> Industria M�,,,,rnn.x ❑ Open Bottom El Manteca Din of Well Excavation /r7. 018 of Well Caring <br /> sec <br />(I Domestic/Private Gravel Pack f7 Tracy Type of Casing____ PVC_ Specihcadon! --q <br /> I'O�ArtrN <br /> I Ptibl+c i 1 Other I1 Delta Depth of Group Seal Typo of Grout <br /> I In+gatian pp <br /> A rax D6171111I I Easlarn Surface Sour Installed by <br /> 1Repair Work Done U type of Pump sl P :L-/A - Stale Work Done <br /> sealing Aaterial i Depth <br /> ell Destruction 0 Well Dinme,er <br /> Depth Filler fiaterial = Depth <br /> YPE OF SEP IC WORK NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I 1 availableNO sorwthin 200 feet system Ittif prrbbc sewer Is <br /> Installation will serve Residence - Commetelal ____ Other <br /> bar of living units Number of bedroom! <br /> ratter of soil to a depth of 3 feet Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No Compartments <br />�KG TREATMENT PLT n Method of Disposal <br /> Distance to nearest Well Foundation Property Line <br /> 1EACHING LINE 0 No 8 Length of lines Total length/arse <br /> ILTER BED FI Distance to nearest Well Foundation Property Line <br />(EEPAat PITS 11 Depth Sire Number <br /> LIMPS ( I Distance to nearest Well Feunrlstion Property Line <br /> ISPOSAL PONDS 0 <br /> I hereby certify that I have prepared this application and that rhe work will be done in accordance with San Joaquin county ordinances state laws and <br />� duses anrsgulatrnns of the San Joanrdn County <br /> 4ome owner or I+csnsed agent a signature certifies the following 'I rerlify the, in the frerformance of the work for which this permit is issued 1 shell not <br /> mploy any Person to such manner as la become subject to workman s compensation law! of California on s hiring or sub contracting signature <br /> comities the following I certify that in the performance of the work for which this permit Is issued, I shall employ person!subject to workman a cornpensa <br /> 1.,,isn laws of California " (S <br /> applicant mull cel! for all required inspections Complete drawing on reverie side <br /> Signed x ^ Title �G'lc� S r S� Data �� <br /> l[pplicaflon Accepted by j <br /> FOR DEPARTMENT USE ONLY S7_ �r <br /> 1/ �U <br /> ,f� � Area�� Dote9 a9z or 0 <br /> I or Grout Inspection by nate Final Inspection by Date <br /> Id'ditional Comments <br /> pplicsnt - iletnrn all coPinn to San Jonquln County rublic lleaith 9ervicen <br /> Environmental flcelth Pprmit/Services <br /> 445 N Ran lonrlutn, P O tiox 2008, atkn, CA P5201 <br /> iv fEE AMOUNT DUE AMOUNT nFMITTEb Cx nEcrivt:d SY OATE PERMIT NO <br /> INFO CASIf <br />�24,aEv +Iasi <br /> 5z37 1 q 7 yZ 92 371- <br /> 2e <br />