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APPLICATION FOR PERU SJOAQUIN COUNTY PUBLIC HEALTH ENVIRONMENTAL HEALTH!.DIVI;S ON VICE P P O BOX 2009, STOCKTON. CA 95201 �1 (209) 468-3447. 1� oc-r 2 1990 If (Complete in Triplicate) � 4 Acstlon is hereby made to San Jon uin Count for 1I- �NV1R N�SERVICES AL HEALTH 4 u permit to construct and/or install th�F IT scribed. This �. �lfcatfon is made in coa:gliance With Ban Joaquin County Ordinance Ho. 5b9 and 1$62 and the Rules sad Regulations of San oagUlu COUAtY Public Health Servicee. �a Job Address 0 r \1 r Ot I City Lot Size/Acrea$e ~ r 4-te- 1 -- Owner's Name C' 4 v f N 5 rt N G Address 1 y 14 C 1` w�f 0 41 6 Phone I110 T- 500 `_ (( 1 5'u� Fa*'104, CA 44583 Conlraclor�lei! �[-r`N4L�A�dress� L4090 P'Ke w"41 Svti fe n License No._ 34343_Phone i$ � —7 $ TYPE Of WELL/PUMP: NEW WELL O WELL REPLACEMENT,)n DESTRUCTION Cl Out of Service Well ❑ PUMP� INSTALLATION D SYSTEM REPAIRj❑ OTHER p Monitoring well DISTANCE TO NEAREST: SEPTIC TANKjfllK"o•wtd SEWER LINES DISPOSAL FLD.16 PROP. LINE 0 / FOUNDATION _.-IkL _„ AGRICULTURE WELL 00 1� OTHER WELL fv 1, PITS/SUMPS ,114KlliWq INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial 0;Open Bottom 1 Manteca Dia, of Well ExcavationZS ' �2,._ Dia. of Well Casing Domasfic/IZivate 0 Gravel Pack L) Tracy Type of Casing Specifications Q Public xOther p Delta Depth of Grout Seal / b 2h f G:�1 Type of Grout irr+UauonAppros. Depth ❑ Eastern Surface Saul Installed by sifirn Lci fic 121" fLoo Repair Work Done L3 Type of Pump a inti _ H.P. '{ _ Well Destruction 0 Well Diameter r � Sealing Material i Depth Stam Work Done Depthft Qf r T biller Material 4 Depth Il TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIRIADOITION M DESTRUCTION G (No septic system permitted if public sewsr is l available within 200 feet.) i Installation will serve: Residence .� Commercial— Other I - Number of-living units: Number of As a ooins Character of foil to a depth of 3 feet: Water table depth SEPTIC TANK. O Type/Mfg Capacity 1' No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line If LEACHING LINE Cl No. b Length of lines I�Toial length/size ? FILTER BED n Distance to nearest. Well Foundation Property Line SEEPAGE PITS i I Depth Sim Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 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 Sen Joaquin County ! ' Moms owner or licensed agent's signature certifies the following: "I canify that in the perform ance 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 certily 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 applicant rnyrs cad for all r Yed inspections. Complete drawing on reverse side. is Signed Title: Dale: FOR DEPARTMENT USE ONLY Application Accepted by 'Date Area Pit or Grout Inspection b ln by Date - s Y Date Final Inspectio Additional Comments: 1� Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIICBS ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES } 445 N SAN JOAQUIN, P O BOX 2008, STUCXTON, CA 85201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEI.4 p By DATE PERMIT NO, } INFO CASH FM 13-24 IIIEv.+r s, 5� /v �) V �y� E""•10 cY[ I C/ f