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,moo APPLICATION"FOR PTRM17 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' . ENVIRONMENTAL HEALTH DIVISION ` 445 N SAN JOAQUIN, PHONE (209)46$-3420 /<r ;0(3 W-3179-0I ` P 0 BOX 2009; STOCKTON, CA- 95201 ' PERMIT E%PIRESI YEAR_fROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the cork herein described. This application is made in cotspllance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County,'Public Health Services. r Job Address `t a pF_L..J iFy2 20r City Lot Size/Acreage ✓tT T2t;<cN h w Owner's Name T Address __.�_�F ____ _ __ '__ � Phone ContractorSP Address �. m),A: 7_R 57: License No, 2•-2-6(3 Phone 9ge_13yS" tTYPE OF WELL/PUMP: NEW WELL C1 WELL REPLACEMENT n DESTRUCTION ❑ e f PUMP INSTALLATION ❑ -SYSTEM REPAIR.❑ OTHER 1• DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. -PR(5P'tINE = o FOUNDATION AGRICULTURE WELL OTHER WELLr VQ ZO 90,114�N65 INTENDED USE TYPE OF WELL - PROBLEM AREA CONSTRUCTION SPECIFICATIONS r Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Diaat Well C ' nF n Domestic/Private ❑ Gravel Pack n Tracy Type of Casing_ pea Ica s ruby I'I Public: El Other .1 1)Delta ^' Depth of Grout Seal 11 I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by M CE-Zo /)711774f- Repair GRepair Work Done ❑ Type of Pump' H.P. State Work Done _ WILG C3 KF-rLG 1 Well Destruction p Well Diameter� Sealing_Material.i Depth t r1-yot-6 0L U6 r. Depth r ifiller Material A Depth IIS- 6iW TYPE Of SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is -- p Y . ,� ". _..•... available within 200 feet.) � Installation will serve: Residence_. Commercial Other Number of living units: Number of bedrooms Character of sail to a depth of 3 feet: f Water table depth SEPTIC TANK. ❑ Type/Mfg r Capacity No. Compartments PKG. TREATMENT PLT,Ll Method of Disposal t r Distance to nearest: -. Well Foundation Property Line LEACHING LINE C1 No. & Length of lines ` Total length/size FILTER BED ❑. Distance to nearest: Well Foundation t Property line �. SEEPAGE PITS I I _Depth # Size Number SUMPS Ll Distance tof nearest: Well t Foundation .Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done inaccordancewith San Joaquin county ordinances, state lays, an r rules and regufations of the San Joaquin Countyt� Home owner or licensed agent's eignaturs'rartifies thefollowing: "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 lawn 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 Uwe of California." The applicant m st call for at uired inspections. Complete drawing on reverse side. Signod �i.�6. 6 I ST - ,,.,_ Title: 6F�OL;;D C3—/Q--9 Z .... Data: �__ __..�. OR EPARTMENT USE ONLY Application Accepted by Date 10-93-72-- Area - Pit or Grout Inspection by Date Final Inspection by Date z t Additional Comments: Applicant —Return all copies-to:San Joaquin County.Public Health Services ( Environmental Health Permit/Services _ - .445•N San Joaquin, P O Box.2009,. Stkn, CA 95201F' / INFO E AMOUNT DUE I AM/O'}UNT REMMITTED H RECEIVED BY J}DATE PERM1�I7•NO• . EM 1124(REV.I/ti 5) 36 f{ Jr" ( EH 14-n [[JJ l