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e t:HviHONmENTAL HEALTH DIVISION V ��%� P O BOX 2009, STOC%TON, CA 95201 i[ O (209) 468-3447 PERMIT EXPIRES T YEAR PROM DATR TC�r=� 1 5 1995 (Complete In Triplicate) Application Is hereby made to Sm Joaquin County foraPermit ENVIRONMENTA application Se made Sn coePllance vl th San Joaquin CounOrdinance npoLru549ct annd o1862amd tie Raul ma'Py ay onebed. of SanThis Joaquin County Public Health Services. Job Address _�S(J�S`^/ „�j�y,�@7� D Lot Site/Acreage ^/ZD X/24 Owner's Name4 1? �d X 4 GR 7dl r 0 S p p } Address 0,_ Z /� 9 ��a Phone Contractor �l�iC/ fes � � 't Address 173V/•4A lgy u I k— License No. 7.�x phone_ lone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT DESTRUCTION O Out of Service Well O O PUMP INSTALLATION O SYSTEM REPAIR O O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial O Open Bottom Manteca Die. of Wall Excavation /D r Dia. of Well Casing 2 f U Domestic/Private j 6raval Peek O Tracy Type of Casing pVC' Specifications Ewe— M Public Cl Other O Delta Depth of Grout Seat Type of Grout ntd crznµ/ n C1 Irrigation _Approx. Depth O Eastern Surface Soul Installed by Repair Work Done U Type of Pump , H.P. State Work Done _ J Well Destruction O Well Diameter Z ¢n Sealing Material i Depth Depth Piller Material L Depth TYPE OF SEPTIC WORK: NEW"INSTALLATION O REPAIR/ADDITION 0 DESTRUCTION U (No septic system permitted if public sewer is available within 200 lest.) Installation will serve: Residence_�b*domol-,! -martial_ Other f Number of living units: Nu Character of soil to a depth of set: Water table depth \i` SEPTIC TANK. O YW/Mfg Capacity No. Compartments II PKG. TREATMENT PLT - Method of Disposal Dlstance to eerest: Well Foundation Property Line LEACHING LINE Cl . 8 Length ofIt as Total length/size- FILTER BED Distance to sat: Well Foundation Property Line SEEPAGE PITS 1 1 De Sire Number II i SUMPS - LI I,rance to nearast: Well Foundation Property Line - DISPOSAL PONDS - I hereby comity that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the Sen Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that In the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compense, 'I lion laws of C Hornla." The spplica test tall f r requir in ns. COmplate drawing on rs ease sidles Signed X O Title: Date: aI J FOR DEPARTMENT USE ONLY ' q� ;F,5;F,5 [1p Application Accepted by -- Date ( Area I Pit or Grout Inspection by Data Final Inspection by Date Additional Comments: 'S Z Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 H SAN JOAQUIN, P O BOK 2009, STOCKTON. CA 95201 UUU FEE AMOUNT DUE AMOUNT REMITTED ASM RECEIVED BY DATE PERMIT'No. FEEINFO pp Q /S :HUN IxlV.t/-al 545 �r b // -