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2MIXIT EXPIRES I YEAR FROM DAM ISSUM (Complete in Triplicate) Application is hereby made to San .'oaqu!r. Ccunty for a per-m]t to construct and/or instal..: the vor} herein described. ':his application is made in cotwU an a with Sar. .loaquln County Ordinance No. 5?.9 an4 1862 and the Ru-ea and ReguLst!ona or San Joaquin County Pu1011c ,Health Services. _ob Address c L�m-Sr--_-�^ f - C tv Fr_e�vs of 5:zc.`�crcage�Te ,x�lJ� Owner's Na"& ` h11]j_. PRSj��L_ Address its?�LL4 Li(f- . s�k�/. Pho, r r• — 'a Conhauo P\-t2 2 cress l.i:ensc No. a^one TYPE OF WELL,P;fs!P NElr11 WEIL a WELL REPLACEMENT DESTRUCTION Out of Service Wei1 -1 ' PUMP tiSTAL-ATiON E SYSTEM REPAIR LI OTHER L:. tions toring Well 17 DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES :?SPOSAL FLO. PROP LANE -_-- FCUNDAT,ION AGRICULTURE WELL OTHER WELL __. PITS;SUMPS 1NTFNDEO USE TYPE OF WELL PROBLEM AREA CONSTRUCTfON SPECIFICAT,ONS I Indtatr a• 0 Open Bottom i-i Manteca Ola of Wel- Excavat.on _ eta. of Well Casing DorreslicrPervate Cl G*ase: Pack !-j Tracy Type of Caa.ng _ _ _-_ Soec•t•catiars�_ Pubuc I,Othter I Delta Depth of Grout Seal __ __ Type of Grou; ! lrrgtat.r)r. _ Ap;vou Depth Eastern,, Surface Saul Instal,ad by Repan Work Done -7 Type of Pump 'H.P _._- State Wnrk Done Well Destruction L We`I Diameter .--__ Sealing Material L Depth Depth _ Piller Material i Depth — TYPE OF SEPT+C WORK. NEW INSTALLA'ION JW REPAIR,ADDITION : CASTRUCTION i 'No septic system permitted .I pnbl.c sewer .s available within?'JO feat.l � Installation well serve Res dente Commercial _ flfhAf „ t Number of living urils: _I Number of bedrooms Character of sod Io a depth of 3 feet —Water table depin SEPTIC TANK S Typo!Mf9 /�tN P�i�'F r!r�A�'+ tE C4pacay-4?D0L_ No. Compartments .` PKG. TREATMENT PLT. 71 Method of D3posal 7Cli 41,p r Distance to nearK,t. Well /b f) Foundation Prnperty Line Is LEACHING LINE No. b Length of lines.3- b 37, _ Total ,en th; >>;e�r_�� a w1d� n - FILTER BED t_: Distance to nearest Well /In Foundation - /d PTA L,ne s y SEEPAGE PITS I pepth 9 Sire Number SUMPS y71 Distance to nearest. Well /S66'_ Foundaaon -./6 Property Line C_ - DISPOSAL PONDS I hereby Certity that I have prepared this applicat•On and that the work wilt be Bono in accordance wt"i Sar Joagjin county ordinances, state taws, Ono rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following -I certify that in the polorrndnce of the work for which this permit is issued, 1 shall not employ any pe-son .n such manner as to become sublect to workman's compensaf on laws of Califarrna " CCntractor's hying or sub contracting signature Certifies the follsw,ng. "I ce►titV that.n the performance of the wArk Mr which this perm;'is.ssued, 1 shall employ persona avblect to workman's co.nper+sa bon laws of California - The applicant uft call r 1 rtrq red Inspections Complete draAnng on reverse aide. S;gned X-4La _ ___ _ TIUe- Da ` �— ro: FOR DEPARTMENT USE ONLY APpi"tion Accsptaa by __ =1 p ►.fey_, Data Area Q-Z-1- Pit or Grout Inspeclion by _ Date -_ Final Inspection by '�.+ �fi�7 Date Additional Comments.