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P. MIT SBPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby ads to Sao Joaquin County for a permit to construe; and/or insult the work herein. described. This <br /> application is made 10 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules said Regulations of San <br /> JaaQuin County Public Health Services. <br /> Job Address � _S C,-,y �n 1 �. Lot Site/Acreage /ZA _ <br /> Owrwr'e Name r S Address ` �� • r "�- Phone <br /> Contractor � Pyr Adaiesi 02J7 :2?- , i I L cense No. Phone <br /> TYPE OF WELL/PUMP NEW WELL C WELL REPL ACEMFNT : DESTRUCTION "� Out of service well Ce <br /> PUMP INSTALLATION G SYSTEM REPAIR 71 OTHER C Monitoring Well n <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FID. PROP LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL— _ __ PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION_SPECIFICATIONS_ \ <br /> C i Industrial G Open Bottom G Manteca Du of Welt Excavation Dia. of Wes Casing <br /> (' Domestic/Prrvats G Gravel Pack 1-1 Tracy Type of Casing Specifications \ <br /> I" Pubic I.' Orta C1 Delta Depth of Grout Seal Type of Grout <br /> ! I Irrvatwn _Approx Depth I I Eastern Surface Saw Installed by <br /> Repave Wort Done J Type of Pump _ H P. State Wor► Oons <br /> Werl Destruction n Well Diameter _ Beating Material i Depth <br /> Depth Filler Material • Depth <br /> TYPE OF SEPTIC WORK, NEW INSTALLATION I ' REPAIRrADDITION I t DESTRUCTION 1 INo septjc system pormutlad it prebic ewer is <br /> available within 2W INI.1 ` <br /> IMteNatwn will serve Res�Oervice Commarceal _ that <br /> Number of Wong urnrls: Number of b9drooms � <br /> Q / <br /> Character of aoll to a depth of 3 fast: Water table depth <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments T rt <br /> PKG. TREATMENT PLT.❑ / 4 / / Method of Disposal <br /> D+aance,to nearest: Well E[( Foundation _A6 Property Line�[Z_ <br /> LEACHING LINE �r No. i Length of lines �� Total Isrtpth/sjie .____ Z <br /> FILTER BED 10 <br /> Distance to nears": Well _1�s Foundation /d' Property Line <br /> r r <br /> SEEPAGE PITS Depth Suis Number _ <br /> SUMPS > I Datance to Clearest: Wolf Foundation Property Line (X/2 <br /> DISPOSAL PONOS 0 r <br /> hereby cantly that 1 have prepared this application and that the work wrlr be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regu{al,oria of the San Joaquin County f" <br /> Hatt owner or 1KW"d agent's signature csnrfes the logowtng "I-Cerfify that in the performance of the wort for wnjch the%peanut is issued, 1 shall not <br /> employ arty person in such manner as to become wbfeci to wwkrtnon's compensation Tawe of Caifarrnra " Contractor's hiring or wb-contracting signature <br /> eerdfiee tie lobw+ng• "1 cemty that m the performance of the work for which this permit is issued. I•lute employ persons subject to workman's compensa <br /> WA baa of California." <br /> The apptwArit must coo for M required inspections. Complete drawing on reverse side. <br /> Signed X_ .�� ��% _ Title: -�� Date: <br /> ---- : <br /> f� JA DEPARTMENT USE ONLY I , —' <br /> Application Ace" by Q H QKy y\\`n, ^ Data —1�_ Aras 1 Z- ^� <br /> 116, <br /> „_' _— © .i <br /> PIt or Grout Inspection by _ Date _ Final Inspection , % I <br /> by� 7 DateZ.- <br /> Additional Comwtents-, <br />