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AVVAA'a,& ..�.�..� ...,. ...... ..,,,..�..... ....... ..� ... .. yam....... .� ».._. .,. __-- -•-- ---'- '------ <br /> application Is made in compliance With San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> FA.lob Address ^.--7�0 aVST�Iu I_'L1CA Let hlsrr'l..:reegc L 1\Ct�C.3- <br /> Owners Name V"� _ TP"ON Address Q <br /> t�acta 1 1 CA[u )te—Andress 1 !0-- -8V I�C�iJ r`4VeL, ,_ense No.��B P",one @23 -S8 <br /> TYPE OF WELL."PUMP NEW WELL D WELL REPLACEMENT - DESTRUCTION C Dui of Service Well O <br /> PUMP INSTALLATION O SYSTEM REPAIR L- OTHER C- Monitoring Well <br /> DISTANCE TO NEAREST, SEPTIC TANK SEWER LINES - DISPOSAL FLD.__ PROP LINE <br /> FOUNDATION AGRICULTURE WELL _ _ OTHER WELL PITSlSUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> -! Industrial U Open Bottom C: Manteca Dia of Well Excavation M Dia of Weil Casing _. <br /> DomesaclPrivate Cl Gravel Pack L. Tracy Type of Casing _____ ___ _ Spec+lrcat+ons _ <br /> I Public ! 1 Otha( I-) Delta Depth of Grout Seal _ _ Type of Giout <br /> - I IrriUation _ Aplvox Depth 11 Eastern Surface Saw Insimled by-- <br /> Repair Work Done U Type of Pump H P — State Work Done <br /> Well Destruction O Wall Diamatef Sealing Matertal i Depth <br /> Depth _ Piller Material i Depth <br /> TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR.,ADDITION . DESTRUCTION :' (No septic system parmiltud of public seam is <br /> available within 2W test I <br /> Installation will serve Res, ice Commercial Other <br /> Number of loving units- Number of rooms.. <br /> CharstlM of soil to s depth of 3 testP J�`' _ _ Waist table depth C <br /> SEPTIC TANK D TypelMlg E ` "Cspsc�ty OU No. Compartments <br /> PKG TREATMENT PLT CI t Method of +sposal " <br /> Distance to nearest Well Foundation Property Lined f <br /> LEACHING LINE L'rNo A Length of lines Tow length/size- <br /> -FILTER BED IJ D.siancs to nearest. Well Foundation Property Line _ <br /> PAGE PITS iT--Deoth Size A _ Number L—»� <br /> ' <br /> IMPS til Distance to nwrest WeWell ��j, Foundst.on .5 Property Line 60 _ <br /> DISPOSAL PONOS i-) <br /> i hereby unify that I hove prepared this application and that the work will be done in accordance wish San JDaQUin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following "I certify that in the performance of the work for wftich INS permit is issued. I shall not <br /> employ any person in such awriner as to beco subject to workman's compensation laws of Canforma Contractor s hiring of sub-contracting signature <br /> certifies the loflowrng: "I certify that in the 1saR mance of the work for which this permit is+ssuoo 1*hall employ persons subject to workman's compensa <br /> tion laws of California." I <br /> The spot <br /> m sip for W r ins Pons Complete drawing on to rss side. `9 <br /> Signed N"'% Title _-- �--_ Date. <br /> FOR DEPARTMENT USE ONLY <br /> O <br /> Application Acceptao by Date <br /> Pit or Grout Inspectionb /� Date J Final Inspection by Dated _ <br /> Addiironal Comments. 4,16 lt.f ,04 �Jlvolth AVIA1•rant - Return alt copies to: San Joaq -_ :ount Public Service~ <br /> Environmental Health Permlt/Serviceti <br /> 445 N Son Joaquin, P 0 Rox 2009, Stkn, t'd 45201 <br /> FEE AMOUNT OtIE AMOUNT REMrTTED K RECEIVED I!Y pATE PERMIT Np <br /> INFO 1 CASH �1 r <br /> t:N 1324 CIIEV x,.51 _ l^ ; _I �n , cl - ; r C r -d 9 -a - <br /> EH <br />