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i APPLICATION FOR PERMIT r='� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Z -04�u ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON,, CA 95201 (209) 468-3447 RX"IT EXPIRES 1 YEAR PROW DATE ISSUED (Complete in Triplicate) Application Is hereby made,to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Healthc,SerZ--P-171 s. Jab Address _. 22 a � , „d i •� t City L 0�3 Lot Size/Acreage rR(�_ Owner's Name VERA) V1 C 9R B Address33 y _d 5 Phone ctorLL SQ Address CJS/QContraLm I TYPE OF WELL/PUMP: NEW WELL / WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION C/ SYSTEM REPAIR ❑ OTHER C] Monitoring Well E� DISTANCE TO NEAREST: SEPTIC TANK �¢� SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYY�PE�•OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,• n , 0 Industrial 11415pen Bottom ❑ Manteca Dis- of Well Excavation Dia. of Well Casing �j �J✓} _W-60mesticlPrivate ❑ Gravel Pack n Tracy Type of Casing - Specifications C1 Public Cl Other p Delta Depth of Grout Seal Type of out �✓ CI I►nUauon ,-•�,Ap'pfox. Depth C1 Eastern Surface Seal Installed by —L—CIC Repair Work Done 0 Type of Pump 5,J Z- H,P. — I State Work Done _ Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i�Depth TYPE OF SEPTIC WORK:_NEW"INSTALLATION 0 REPAIRIADDITION L7 DESTRUCTION G INo septic system � R permitted it public sewer is available within 204 feet.) Installation will serve: Residence_ 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. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No. 8 Length of lines Total length/sire ' FILTER BED ❑ Distance to nearest: Well Foundation Propeny Line SEEPAGE PITS 11 Depth Sire Number SUMPS Ll Distance to nearest: Weil Foundation Property Line DISPOSAL PONDS ❑: r' 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 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 applicanm call for quired inspections. Complete drawing on reverse side. 4 SignedTide Data: / >✓ . F RDE ENT USE ONLY f Application Accepted by 4tA., �C ��_ t, Date �^-1 �.� Area P Grout ! spection by Dat /� �r Final Inspection by Addis onal Commanta: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON. CA 96201 FEE AMOUNT DUEAMOUNT REMITTED CK gECEIVED BY PATE PEAMIT'N0. INFO CASH . EH 13•24 tREV. i al N w OC'� oo l 4Intl 'Z'77-- FH i4•20