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APPLICATION FOR PERMIT it SAN JOAQUIN COUNTY .PUBLIC HEALTH SERVIC� r ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-342 �. P 0 BOX 2009, STOCKTON, CA 95201a PERMIT MIRJRY _P. FROM- DATE (Complete in Triplicate) ENVIRONMENTAL.HEALTH EE�� ITISF Application is hereby made to flan Joaquin County for a permit to Construct end/or install the von ere n�RVeW abed. This spplication is made in compliance vith Sen Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San + Joaquin County Public Health Services. Job Address G 3 Weir -7RFE-T _ City Lot Size/Acreage ` Owner GITI� 0 TtlAc-y--- Address SZ-0 -TRhc tal_UD, �Tk G Phone ZO ?6f Z(Z0 s Narrae i x, �' �� n✓ r`►'" 11e f r �J u ZG Y6 Phone Conhactt� .� �C Address_ - License No, I TYPE OF WEi.L/PUMP: NEW WELL ❑ WELL-REPLACEMENT Cl DESTRUCTION ❑ Out of Service well ❑ � PUMP INSTALLATION ❑ SYS'rEM REPAIR ❑ OTHER ❑ Monitoring well DISTANCE TO NEAREST: SE,I PTIC TANK SEWER LINES' . DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CO,NSTRUCTIOWSPECIFICATIONS i 0 Industrial ❑ Open Bottom ❑ Manteca Dies. of Well Excavation_6 fr101f Dia. of Well Casing Z l WGH n DomesticlPrivate Gravel Pack ❑ Tracy Type of Casing_ [ v Specifications S crf i=D. _ I'1 Public nOther (l Delta Depth of Grout Seal �Xf�" Type of GroutNCA c C- Sr7fGS �X LUiysT/O✓ SEn'V/�FS R I I Irripatian ...�Approx, Depth 1 I Eastern Surface Seat installed by Repair Work Done L7 Ty'` of Pump tVIA H.P. A - State Work Done _ C F ,i er •2 , tn►[i� Sealing Msteri al i Depth C OU 7 �- .-T a-_ rlr--'� ❑ W Well Destruction Well Diameter _- Depth ^'ZS Fd5ET- Tiller Material i Depth ` SAND �r 2S -- 1 fy TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADOITION I I DESTRUCTION I I INo septic system permitted if public sewer is IN available within 200 leet.l installation will serve: Residence _ Commercial— Other . Number of living units: IM Number of bedrooms Character of soli to a depth'l 3 lest: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ I� Method of Disposal Distance to nearest: Well Fo►:ndetion Property Line -� IM g LEACHING LINE Cl No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation.— Property Line IM SEEPAGE PITS It Depth Size _ Number SUMPS Lk Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ IN ; I here certify that I have by ly prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and j rules and regulations of the Son Joaquin County 1 Home owner or licensed sgentls signature cenifias thi'fohowing: "I certify that in the performance of the work for which this permit is issued. I shall not employ any person in such manrMr as to bacons subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which th:s porn-it is issued, I shall employ persons subject to workman's comlpensa• tion Iowa of California." p 1 !` The applicant rrwst call for al1l°�uirad inspections. Complete drawing on reve,se side. I / �. S R /Z-Z l Signed Title: �' 7 �7FdLdIS_ --- Date: �T I� FOR DEPARTMENT USE ONLY Application Accepted by tdD Date .� z Area Ph or Grout Inspection by res"' ""` Data 1 Sinai Inspection by — Date j Additional Comments: Applicant - Return sill les to: San Joaquin County Public Health Services Environmental Healtb Permit/Services 8 P�[ 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 (431 F FEE__ INFO AttOUNT DUE AMOUNT REMITTED x5� RECEIVED 1!Y DATE PERMIT'NO. ! J . Ew 5 2 11 . wi � PAA Lq--571..+ � II