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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468--3447 (Complete in Triplicate) t 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. 544 and .1862 and the Rules a-nd Regulations of San Joaquin County Public Health Services. T Job Address r)1 C��,2 Al Er v_e.1Za--- _ ---_ty 21f=4 1,� Lot Size/Acreage Owner's Name /,(.1' a�'.,�C -. _ Address 69�O_�!`-) {. a-U,e.!/4 CL - Phon Contractor` l_J� ddress4Q,- _ - ,a� License rio.Cd ``- PhoneCn`��Z� - j TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well G7 PUMP INSTALLATION SYSTEM REPAIR 0 OTHER 0 Monitoring well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES w DISPOSAL FLD, ��/Q PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL er_n -- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS M Industrial Open Bottom ❑ Manteca Dia. of Well Excavation _ pia, of Well Casing Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing��P� SpecificationsIvr � M Public is Other ❑ Delta Depth of Grout Seal iQ42 Type pf Grout j r-I Irrigation c P .Approx. Depth � ��Eastern Surface Seal Installed by / / _ F.s�f c—L _ Repair Work Done U Type of Pump H:R:� tate Work Done _ Well Destruction ❑ Well Diameter Sealing-Hateria-1:4 Depth - Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITION 0 DESTRUCTION CI INo septic system permitted if public sewer is available within 200 feet.) n, Installation will serve: Residence— Commercial— Other � �. y �,,� yJ Number of living units: Number of bedrooms ; Character of,soil to a depth,of 3 feet: * -- Water table depth ' SEPTIC TANK. ❑ -Type/0-9 Capacity No / PKG. TREATMENT PLT. 0 " Method of.Disposal Distance to nearest: Well Foundation Property Line- 'LEACHING LINE Cl No. & Length of lines ' r7otal lengthlsiie "FILTER BED n Distance to nearest: Welt Foundation . Property Line SEEPAGE PITS 11 Depth Sire } Number r a SUMPS Cl Distance to nearest: Well ,Foundation j Property Line P DISPOSAL PONDS O V I hereby certify that I have prepared this application and that the work will be-done in accbidance with San Joaquin county ordinances,-state laws, and rules and regulations of the San Joaquin County Hpme-owner-crlicensed-agent`s signature-cenifies the-following:'I-certify-that-irt-theImrformance-of-the-work-for-which-this-permiT-is-issued, 1 shall not,, employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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 Iowa of California." The applicant must call for all required inspections. Complete drawing on reverse side. / Signs TitleZ Date: FOR DEPARTMENT USE ONLY C.- Application Accepted by�'z�m _ Date 2 /� I Area 4 P' r�Groutlntion by—� � `, T Dater 7 Final Inspection by _'_I� Off! Data —�C Additional Comments: S V Applicant - Return all copies for SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES i 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON. CA 85201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH . RECEIVED BY DATE PERMIT NO. ! + Ell13.741REV. /r5! LO� '— �1 E14^4•ie y