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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 Y' (209) 468-3447 Oftl�m -{z M&A��.S 3� 3y67lvW , R A,-f 3T Yr (Complete in Triplicate) — 31aa Application is hereby made San Joaquin County for a permit to construct and/or install the work herein described. This application is made in oceWliance with San Josqui County Ordinance No. 549 and 1862 and pthe Rules and Regulations of San Joaquin County Public Health Services. /1 �_. Job Addreaa/VO. �i�tflf"�SFlrr(Qul^1FT?`I 1 __ CityV . .._ Lot size/Acreage Owner's Name — Address A '66K, �4;�5189 � �� Phone 9M 874t? Contractor ress Ee M YAZ_JZ..-V-_N2TL,icense No. 51Z2b8 Phone ?q13-13y TYPE OF WELL/PUMP: _ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ftT-OT-Se—rvTcf PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Yf 14684%914" we" TJ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. Rena 61011i i/Z 71MT 00141,16 FOUNDATION AGRICULTURE WELL OTHER WELL tr0/6-01 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS s,fp36-1 n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation lv U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing r6pacifirattt3sts ❑ Public 1:1 Other ❑ Delta Depth of Grout Seale-vf•Srtsnt G Irrigation —.Approx. Depth ❑ Eastern Surface Seal Installed by r�-t� PL6 tf Repair Work Done 0 Type of Pump H.P. State Work Done W Well Destruction O Well Diameter Sealing Material i Deptha Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION M DESTRUCTION CI (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence— Commercial ^ Other Number of living units: Number of bedrooms Character of wil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED n Distance to nearest: Wait Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i I hereby certify that I have prepared this application and that the work wilt 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 note 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, t shall employ persons subject to workman's compensa- tion laws of California." The applicant uaI III it required inspections. Complete drawing on reverse side. Signed X Title: .eff&111t ! &n 1 S? Date: V-3-71 F R PARTMENT USE ONLY Application Accepted by Dats Pit or Grout Inspection by Date Final Inspection by Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON. CA 95201 FEE INFO AMOUNT pUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. . EH 13,24IREV.rInsl �[ ! I—LLt EH 74.26 CJJ