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Job Address 2024s- W. Ac/4,1 )r--772c) City S-3:(_,Cea._ Lot Size/Acreage Po- 130x. Owner'e Name 1 Oer1S-i e Lbe C Address Pi UeK-ide CA' License No 6,sTi 7E1% Pnori&e.)637- .7/6S, WELL REPLACEMENT 0 DESTRUCTIONXOut of Service v e il 0 SYSTEM REPAIR Cl OTHER 0 monitoring well ,ts< SEWER LINES 25' DISPOSAL FLDA./././ef PROP. LINE 1'0/ AGRICULTURE WELL /1/./4 OTHER WELL 4///1 PITS/SUMPS 47_4 TYPE OF WELL PROBLEM AREA 0 Open Bottom 0 Manteca 0 Gravel Pack 0 Tracy 0 Other 0 Delta Approx. Depth 0 Eastern U Type of Pump Well Diameter Depth DESTRUCTION 0 (No septic system permitted if public sewer is available within 203 feet.) Other Water table depth SEPTIC TANK 0 Type/Mfg Capacity_ No. Compartments PKG. TREATMENT PLT. Method of Disposal Distance to nearest: Well Foundation Property Line L E ACHING LINE Cl No. & Length ol lines Total tongthrsize FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Wall Foundation Property Line DISPOSAL PONDS 0 Contractor A--aSsD n' AddtessBa-( &/ 2 I) 0 (4 TYPE OF WELL/PUMP: NEWWELL 0 PUMP INSTALLATION 0 DISTANCE TO NEAREST: SEPTIC TANK /ViA FOUNDATION 7S I") Industrial U Dome stiC/ Private Punk El CI ulwahon H 0 0 6 4 Work Done Well Deetruction INTENDED USE H.P. Suite Work Don Sealing Materiel & Depth CR_ Filler Materiel & Depth CONSTRUCTION SPECIFICATIONS Die, of Well Excavation (51. Type of Casing Depth Depth of Grout Seal <1.2? _ Type of Grout CM. Su4ce Seal Installed by Dia. of Well Casing .2 1 - TYPE OF SEPTIC WORK: NEW INSTALLATION C REPAIR/AbOITION Installation will serve: Residence Commercial Number of living units' Number of bedrooms Character of soil to a depth of 3 feet: CK I RECEIVED BY CASH 65 V-4 AMOUNT REMITTED 0 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERUIT/SERVICES 445 N SAN JOAQUIN, P 0 UOX 2009, STOCKTON, CA 952 AMOUNT DUE PERMIT NO. (06) 5_4fLe On S 442 VIS Applicant - Ratu.ric ail copies to: FEE FEE INFO ,I).2.11AN,t/o The applicSint Signed X. Application pted by Pit or Grout Inipection by Additional Comments: Title' COA"-eit".7:4-t/7— Date: FOR DEPARTMENT DEPARTMENT USE ONLY Date Date`S-}2 741S- Final Inspection by —271 `--7Y1 771 I lo requir d inspections. Complete drawing on reverse side. APPLICATION FOR PERMIT SAN JOAQUIN .COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL liEALTEI DIVISION P 0 BOX 2009, STOCKTON , CA 95201 (209) 468- .342 C) PERIIIT_,EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made .to San Joaquin County for s permit to construct and/or install the work application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules Jcquin County Public Health Services. herein described. This and Regulations of Sun I hereby cenify that I 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 San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the per-to/mance of tho work for which this permit is issued. I shall not employ any person in ;Lich manner as to become subject to workman's compensation laws, of California." Contractor's hiring or sub-contracting siva tufe 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 compenza• tion laws of California." Q - c.0