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APPLICATION FOR PERMIT SAN JOAQUIN COUNTAL PUBLIC H DIV ON HEALTH VICES ENVIRONMENTAL PHONE (209)468-3420 16p1 E. BOX XON , S OCKTON, CA 95201 i P O BOX 2009. , TIRES 1 YEAR FR M DATE (Complete in Triplicate) A---T— S? ' ermit to construct and/or install thepvork her described. This for a p lations of San made San Joaquin County Ordinance No. 549 and 1862 and the Hulas and Regu Application is hereby fiance with San Joaquin County ` application is madillnHeellth ervices' ,_ uis} �> y P sa � j, �/,'f, S,ot Size/Acreage lL�.rL//j}/V' ��1/J YIW� City r � Job Addres Phone j rt��D F Address Owner's Name RRRvvV Phone License No Address DESTRUCTIQN t of Service Well ❑ � I Contractor WELL REPLACEMENT ❑ Monitoring Well C7 NEW WELL ❑ OTHER ❑ TYPE OF WELLIPUMP: SYSTEM REPAIR ❑ o PROP• LINE I PUMP INSTALLATION ❑ ..---DISPOSAL FLO. SEWER LINES P1T5lSUMPS DISTANCE TO NEAREST: SEPTIC TANK �---- pTHER WELL-- k... AGRICULTURE WELL — -- - i FOUNDATION f� ` INTENDED USE TYPE OF WELL PROSL_ EM AREA CONSTRUCTION SPECIFICATION Dia. of Well Casing ❑ Manteca Dia. of Well Excavati` ❑ Open Bottom Specifications-- ----�—"" n Industrial L7 Tracy Type of Casing— —"' Type of Grout------ EI rout ` Cl DomesticIPrivate ❑ Gravel Pack Depth of Grout Seal j I.} Other Cl Delta I'I Public th l I astern Surface Seal Installed by �.Approx, Dep t or, D e i I Ir6i)ation ♦!k(P, Repair Work Done L7 Type of Pump Sealing Material 6 Depth i Well Destruction ❑ Well Diameter Filler Material DepthDepth lwithin 200 feetTYPEOF SEPTIC WORK: NE I S ALLATI I I ;9�� l PAIRIADDlTION 14 DESTRUCTION 4 I ;NO seplicl`system permitted if public sewerks Commercial Other 1 Installation will serve: Residence— I Number of living units: Number of bedrooms ' `Water table depth C3 Character of soil to a depth of 3 feat: --- .., Capacity --- NoFCompartinants SEPTIC TANK. --0—Type7Mf4 Method of Disposal I PKG. TREATMENT PLT.❑ Property Line Distance to nearest: Well Foundation ` r , I Total length/size, LEACHING LINE Cl No. & Length of lines Foundation.._...�..-- Property Line l FILTER BED El Distance to nearest: Well�� I r SEEPAGE PITS 11 Depth Size XIN Number i SUMPS LI Distance to nearest: t Well Foundation_ �--- Property Line D SPOSAL PONDS ❑ ti f I hereby certify that I have prepared this application and that the work w;11 be done in accordance with San Joaquin county ordinances, state las, and rules and.`regulations of the San Joaquin county 11 work for l not Home,owner orgr�licensed such agent's signature gas torbecome subjec�lto wok men'srtcompensation lify that in the aws Californiaoh@ Contractor's which of s b1 cont act ng signt is issued, I laturre amp aV V fie m certifies the fallowing: u certify that sQneperformance of the work for which this permit is issued, I shah employ persons subject to work i an's compensa- 1 tion laws of C lit mia," t �� n G .- -he applicant t. a1 o all a uirc o mplete drawingVr rse ♦' !y Date: t : _.1 Title: ' t Signed X' DEPAR ENT USE ONLY Date Application Accepted by . c Final Inspection by Pit or Grout Inspection by t` Date k I Add'9tion`al Co ants:.,.- t } Applicant - Return all copies to: San Joaquin County Public Health A f F Services, Environmental Health Permit/Services t ; *}11601 E. Hazelton Ave., P 0 Box 2009, Stockton,'CA' 95201 } * t bE t CK t RECEIVED By DATE PERMIT N0. EEE oUNT DUE AMOUNT REMITTED CASH INFO . + EH 13.24 IREV."n 5I EH ,4-28 ��