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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> c P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> l <br /> aicooMAby &*h u1oedeiiSInOa �as <br /> application tin **41140 Vsa Jasqtn Cowry Ordinanam no. $40 and14611 fA thefule► " lUAtOef q <br /> Joaquin County Public Health Services <br /> Job Address 0 / ce • City -5716a Lot Size/Acreage <br /> Owner's Name 13 C U N D C-q-0 Address A. Phone <br /> 2 7` 11411215 <br /> Contractor,DG1/' �V �� Address �O Jt / Lice No L-37 Phone/ <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT 'DESTRUCTIONA Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSfEM REPAIR O OTHER O Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 4` W SEWER LINES loo DISPOSAL FLD. PROP. LINE IdO <br /> / <br /> FOUNDATION AGRICULTUhe WELL OT'HEM WILL. GJ. PITS/SUMPS lJ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �•� <br /> n Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dis. of Well Casing <br /> K Domestic/Private LR Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'1 Public 1--1�Other fl Delta Depth of Grout Seal ZOO Type of Grout <br /> I I Irrigation.Approx. Depth 1 I Fastem Surface Seal Installed by C4 ,Wk,7e_/ <br /> Repair Work Done U Type of Pump H.P. State Work Done _ <br /> Well Destruction X Well Diameter !_ Sealing Material a Depth <br /> Depth Piller Material a Depth <br /> TY ORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted it public sews <br /> Available within 200 feet.) <br /> L Installation will tlenre: Residence_ Commercia <br /> 40 Number of living units: Number of bedrooms <br /> QCharacter of$oil to A depth of 3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg city No. Compartments <br /> PKG. TREATMENT PLT.0 ethod of Disposal <br /> Distance to nearest: Foundation Property Lt <br /> LEACHING LINE C7 No. S gth of lines Total length/size_ <br /> C` FILTER BED ittanee to nearest: Well . Foundation�_�_ Property Line <br /> O <br /> SEEPAGE P I I Depth Site Number <br /> SUMP L1 Distance to nearest: Well Foundation Property Line <br /> D OSALPONDS ❑ <br /> 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the Son Joaquin County <br /> Homs tlwner or lic agent's lignature certifies the following: "1 certify that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any on in suc nner as to become t to workman's compenestion laws of California."Contractor's hiring or sub-contracting signature <br /> ca"till, t following: "I a ify the to th perfo an of the work for which this permit is issued,1 shall employ persons wbjsct to workman'$compensa- <br /> tion Is of Califon s." <br /> The ap Ii It Il r all r uir . Com lets dr eve side. 9 <br /> Signed Title: Date: /O r <br /> ENT USE ONLY g <br /> Application Accepted by Date ^� L'?"_ Area s' <br /> r <br /> Pit o rout spection by OsM4¢� Fihil inspection byAdditional Comments: A. / tJ -/r, <br /> Applicant - Retur l copies to: San Joaquin County Public lic H ith Serviceae <br /> Environmental Health Permit/Sertrices �G <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CV RECEIVED BY DATE PERMIT'NO. W r <br /> • EEH 3-24 H11•t$IREV.vesl <br /> Wk-ULD .vo �"[U 92- 9i c?o�a7 wo <br /> Pie 92 ,01 a P R <br />