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} APPLICATION FOR PERMIT ANNED SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION -445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT 'F IRES I YEAR FROM, DATE 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 cosgliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. I! Job Address L i O K C f City S Lot Site/Acreage ZZ. A C Owner's Name aph 0.of.%Rks Address S�rn� ,r� Phone Conlractor 1� =- —Address-nob ,J 1 License No. 7� -r �77 S 1 _ Phone- *3.y *7 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT l i DESTRUCTION ❑ Out of Service dell ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 'Las 0 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/.SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V' 0 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation i Dia. of Well Casing ,�W Domestic/Private Gravel Pack C7 Tracy Type of Casin 4< '- 9- Specifications I'1 Public 171 Other fl Delta Depth of Grout Seal S O Type of Grout__C�'- C61 I I Irrigation 42Approx. Depth I I Eastern Surface Soul Installed by CBIS A01k, Repair Work Done U Type of Pump r I L-46 H.P. S, State Work Done 92eft 8! rt Q Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Tiller Material i Depth �- x TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION 1-1 -DESTRUCTION-1-1 .(No septic system permitted if public sewer is available within 200 feet.) Installation will_serve—RoWdent;s-,.. Commercial_-Other_ Number of living units: Number of bedrooms' Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. b Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation 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 regulations of trio 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 compansa- tion laws of California." The applicant mussttcall Dr all required inspections. Complete drawing on reverse side. [. Signed 1C_{�dd�� .,.._ Title: 0WANCR Date: z FOR DEPARTMENT USE ONLY Application Accepted by �WlData ' — r Pit Gr Inspection b Date i� � Final Inspection by{� el ' ,/ Additional Comments: 1 A. Applicant - Return all copies to: San Joaquin County Public Healttix§ervices { Environmental Health Permit/Services i 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 �, �FEO AMOUNT DUE AMOUNT REMITTED CK J CASH RECEIVED BY DATE PERMIT'NO. . EN t � IP IV3-a4IREY.iiKSi r g OD ✓ r , __e66 / EM 14•