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APPLICATION FOR PERMIT 3 U SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 2 ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 C E AR PROM DAIE ISSUED (Complete in Triplicate) _ Application is hereby made to San Joaquin County for a 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 and Regulations of Ban Joaquin County Public Health Services. Job Address _J 9 (9 .,L/ —� City Lot Size/Acretige 4`14 F�-. Owner's Nome �R Address • o,,To Phone - Q t �fa R P f -a & i i o Contiat lor&jm4s 1e16I1,9A1(1* •Address 9 4 S' o,:.cr R4 License PPo ' Phone 745•-2.407 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 77 DESTRUCTIONt of SerVice Well [l. i PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER Monitoring Well C7 1 `DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES 1 9 t,.,. _f�,° r . DISPOSAL FLD.� PROP. LINE FOUNDATION �� AGRICULTURE WELL OTHER WELL PITS/SUMPS j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS fl Industrial ;Q,Open Bottom 0 Manteca Dia, of Well Excavation i' c�� Dia. of Wall Casing Domestic/Private ❑ Gravel Pack 0 Tracy. Type of Casing I _N r l=�'� Specifications 2- A Public f:1 Other ❑ Delta Depth of Grout Seal i _ Type of Grout ClC IINa' CJ Irrigation ...�.Approx. Depth 0 Eastern Surface Seal installed by '"c' �_ / 741%W 1%W <-� Repair Work Done U Type of Pump H.P. Soo Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth l "C'ge-K a`juEn c/} G{ +�►QF Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION M DESTRUCTION D (No septic system permitted it public sewer is Installation will serve: - Residence_ Commercial available within 200 feet.) � Other - I Number of living units: . Number of bedrooms �}J Character of soil to a depth of 3 feet:SEPTWater table depth PKG. TREATMENT ETMENT PLT.L7 v l TANK. ❑ Type/M}g . Capacity�T No. Compartments EKG. T Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED CI Distance to nearest: Well FoundationT Property Line SEEPAGE PITS ! I ! Depth Size - � Number SUMPS - y i Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stale 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 performance of the work for which this permit is issued, I shall not employ any person in such manner as to become 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 this permit is issued. I shall employ persons subject to workman's compensa- tion laws of California." The applicant sZcralll r quoad ins coons. Complete drawing on reverse side'. Signed _....... �'.�L�R9e Title. C 1, Date: f a"J i OR TMENT USE ONLY i Application Accepted by / Date T— Area Pit r spection by` Data-r-Z-- Final Inspection by K TM Addi lonal Comments: , w�,,��•." - ,.arm-=;�" Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES F« x -ENVIRONMENTAL HEALTH DIVISION PERU I T/SERVICES" 445 N SAN JOAQUIN, P 0 SOX 2009, STOCKTON, CA 85201 FEE AMOUNT DUE CK INFO t7UNT REMrTTED CASH RECEIVED BY DATE —PERMIT'NO.- • EH,�. IeEv.s,�s, l3 019