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APPLICATION FOR PERI&IT � ° PUBLIC HEALTH SERVICEi' _ SAN soAQazN coNTX I V L U ENVIRONMENTAL HEALTH DIVISION MAY 2 S 1994 p O BOX 2009, STOCKTON, CA 95201 ENVIRONMENTAL. HEALTH (209) 4683.447 PERMIT/SERVICES 1 (Complete in Triplicate) in Application Se hereby made,to San Joaquin County foroa pe Ordinance to onstruct and/or49 end instal tthe Rwors ereRegulstionadof Sans application ie made'in compliance with Joaquin County Public Health.Services. City L_ Lot Size/Acreage ,_IL�,I 1.-•- Job Address SD a S s 1 E X11 Phone Address Owner's Name License h1o. !��-phone ��,} L Address • well Contractor. v��- WELL REPLACEMENT _ DESTRUCTION ❑ fhlt of Service Well NEW WELL ❑ OTHER ❑ Monitoring I TYPE OF WELL/PUMP: SYSTEM REPAIR PUMP INSTALLATION ❑ DISPOSAL PLD. PROP. LINE SEWER LINES _._ ___AL -- DISTANCE TO NEAREST: SEPTIC TANK ,.- OTHER WELL -PITS/SUMPS FOUNDATION AGRICULTURE WEtI_....�-----•__-OTHE INTENDED USE TYPE OF WELL PROBLEM AREA Dia, of UGTIDN SPECIFICATIONS Dia.of Well Casing p Open Bottom ❑ Manteca Dia. of Well Excavation I C.1 Industrial Specifications L7 Tracy Type of Casing �f(1 Domestic/Private ❑ Gravel Pack � Type of Grout — )6 Public !1 Othe w. ❑ Delta Depth of Grout Seal ,� Approx.IDepth{ ❑ Eastern Surface Sea! Installed by y 0 Imijauon 4 H.P. State Work Done 4 M fk Repair Worse Done ❑ Typm of Pump�--- Sealing Materia �, Depth ��_ Well Destruction O Well Diameter ` Filler Materiel i Depth Depth ayailai3le within 200 foet.) TYPE OF SEPTIC WORK ��1NS}�TION 0 REPAIRIAODITIDN l� DESTRl1CTION Cl fNo septic system permitted if pubic sev�'t Commercial— Other — -- installation will larva: Residence �. {� Number of living units:' Number of bedrooms (Nater table depth Character of soil to a depth of 3 feet: Capacity_ No. Compartments ` SEPTIC TANK ❑ Type/Mfgirx �+ Method of Disposal F PKG. TREATMENT PLT. C] Foundation - �-==-�Property Line Distance to nearest: Well _.� �- ': s Total length/size v f= LEACHING LINE ❑ No. 8 Length of lines - r Foundation Property Line FILTER BED _n Distance to nearest: Wet1 j -} t Number, f SEEPAGE PITS ` l 1 Depth Size Foundation, dation •.Property liner -tea-- *- SUMPS Ll Distance to-nearest::_Well, i f k. I DISPOSAL PONDS '•�Ea I hereby certify that I have prepared this application and that the work will be done in accordance with Sante osquin county ordinances, state laws, and �' I rules and regulations of the San Joaquin County ! Home owner or licensed agent's signature certifies the fallowing: "I certify that ir�ha performance of the work for which this psub ermit is issued, I signature shall not a employ any person in such manner as to�omeeman subject ofphe work n'swhichehss parrnitation wi sae eds of ''cofI shall erTip y Persons lsubj cring rt to workman-contract�scompensa certif!as the fol ng; "I caRify that in the pe tion lawn of C lif rnls.": .x The appfic nt ust call for-all requi inspecti s._Complete drawing on raves:a side.Title: Date: � (�/ _r r Signed - J ` FDR DEPARTMENT U5E ONLY /moi , n . l date J /� Area ApplicationrA'jlecopted by Pit or Grout Inspection by Date _ ---- Final Inspection by V` Date ter t Additional Comments, _ t�App]ic'en Return-elf copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES r, tt !!11 ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAH JOARUIN, P O BOX 2009, STOCKTON, CA 95201 § PERMIT N0. CK RECEIVED 8Y DATE '''w•FEE AMOUNT DUE AMOUNT REMITTED CASH INFO -?x.91 1-I; k . EH 13.24 111EY.I s st !v v EH 14.25