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Ir AS&0*I ON FOR PERM I T xat�r;vj' l }UNTX PUBLIC HEALTH SERVICES ITI&ENTAL HEALTH DIVISION 9, STOCKTON, CA 95201 4101 C0 Pl' (209) 4&&-"47 (-10—3 y aef) IT NWIRES I XEAR PROM DATE ISSUED, (Complete in Triplicate) Application is hereby aiade,to San Joaquin Count for I 4 Y permit to construct and/or install the work herein described. This application Is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules sud Regulations of San Joaquin County Public Health Services. ' l3�w,c.uN.. Ser✓i 4C. Sr-�.ria.. 6 yS �� Job Address 00 5ov >`.. G o [ •.c City L aLot Site/Acreage 0d0 FrL Owner's Name l rr ti a+ -�-"^�-• Add ass 5 2 S Wi s.r- X4,-rd` Si• l+G:., arW C-9 Phone 1 U 9- en X 33 G/ - ' Conlraeeor2�i'� 9 _Address 2 etc Imo{l.y License No. sy 1 Phoneu TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER 0 Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK /V4 SEWER LINES 0 90'/i Se DISPOSAL FLD. NA PROP. LINED AW-iff Vw•L C FOUNDATION 8 ZZO" AGRICULTURE WELL ti1�1 0` ' A14 --�--- - .,_...__ _,.__.. OTHER WELLS PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I� L1 Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation "� $r� Dia, of Well Casing '2 r� U Domestic/Private ❑ Grave! Pack ❑ Tracy Type of Casing PVC- Specifications l� ry M Public f�eOther ❑ Delta Depth of Grout Seal '' f" 61 Type of Grout-6--T- G Irrigation ;rSY14pprox. Depth ❑ Eastern Surface Sea! Installed by !M Repair Work Done 0 Type of Pump H.P. State Work Dona Well Destruction D Well Diameter Z"01 Sealing Material i Depth 9,4+rr,tJ.,-riNw. .9- Depth: �S' r:0� Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION CI (No septic system permitted if public sewer is h available within 200 feet.) Installation will serve: Residence_ Commercial Other II Number of living units: Number of bedrooms l Character of soil to a depth of 3 feet: Water table depth If SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments l� ; PKG. TflEATMEN7 PLT,C7 Method of Disposal i Distance to nearest: Well Foundation Property Line !� ! LEACHING LINE Cl No. & Length of linesI� Total length/sire IM ' FILTER BED Cl Distance to nearest: Wel! Foundation Property Line i� ! Iq l� - SEEPAGE PITS i I Depth Sire Number it SUMPS Cl Distance to nearest: Well Foundation Pro h Property Line DISPOSAL PONDS ❑ I hereby certify 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 ragufations of the San Joaquin County d Home owner or licensed agent's signature certifies the following: "I carlity that in the performance of the work for which this permit is issued, I shall not r employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiringor 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 compensa- tion laws of California." 11 The applicant must call for all required inspections. Complete drawing on reverse side. II Signed G /Q GQtn , 7�✓fix T"ev •r,,- Title: SC ..,`dr G-er/v4 .in X(r yi 3r , Date: 2/8 1,71 4 F OR DEPA USE ONLY I Application Accepted by Date r� `' ~� res Pit or Grout Inspection by 7:!5� Date 3Finaf Inspection Date J Additional Comments !` Applicant - Return all copies to: oP SAN JOAQ UIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES !� 445 N SAN JOAQUIN,.P 0 BOX 2009, STOCKTON, CA 65201 FLEE Q. AMOUNT DUE AMOUNT REMITTED CK RECEIVED Y INFO CASH DATE PERMIT NO, a x fill . 1.4-A EN tAEV.iinsi �. U /• OC.J —J .