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it APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISZ;ON P 0 BOX 2009, STOCKTON, CA 95201. (209) 468-3447 PF3NIT UPIRBS YEAR PRQ9 .PAIN iSSiE (Complete in Triplicate) 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 vlth Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 5�° A,"na,± City Lot Size/Acreage 3 I-aylg ICI +� Phone Owner's Name �pAddress ms+µ x 5. '^S ►��t ,l• � l_iCCnSe NO•S 9-2-Za Phoi1 - 17IZ Contractor Addres TYPE OF WELL/PUMP: Ett- WELL REPLACEMENT F) DESTRUCTION ❑ Out of Service Well Ll PUMP INSTALLATION ❑; SYSTEM REPAIR 0 OTHER 0Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD.100'___ PROP. LINE _150 FOUNDATION S AGRICULTURE WELL --OTHER WELL-'75' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Ll Industrial ❑ Open Bottom X Manteca Dia. of Well Excavation_ / Dia. of Well Casing V Domestic I Private Fa Gravel Pack 0 Tracy Type of Casing L Specifications SC6,40 I7 Public I'i Other 0.Delta Depth of Grout SeallSil Ir G[ Type of GroutL°o»cre+ 0 Irrigation 2.5" Approx, Depth ❑ Eastern Surface Seal Installed by Repair Work Done LJ Type of Pump H-P. ' State Work Done_ Wail Destruction O Well Diameter Sealing Material i Depth Il. Depth Filler Material 4 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADOITION 0 DESTRUCTION LJ lNo septic system permitted if public sewer is ! available within 200 feet.) Installation will serve: Residence ___ ''Commercia_ Other I V, Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet Water table depth SEPTIC TANK. 0 Type/Mfg Capacity I No, Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation ' Property Line I� LEACHING LINE 0 No. & Length of lines :Total length/size FILTER BED n Distance to nearest. Well Foundation P Property Line SEEPAGE PITS 11 Depth Size I!Number SUMPS LI Distance to nearest: Well Foundation I;. Property Line DISPOSAL PONDS 0 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 San Joaquin County Home owner or licensed agent's signature certifies the following: "I cerify that in the pedor mance of the work for which this permit is issued, I shall not employ any person in such manner a$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. I shall employ parsons subject to workman's compensa- tion laws of California." ! The applicant T46t call or ail quir nspgc ons. Complete drawing on reverse side. Signed X. Title: L�s�s �h r Date: I� FOR DEPARTMENT USE ONLY, Application Accepted by + �— IfDate �r ��' / Area t w !P LU f Pit or Grout Inspection by Date t Final Inspection byDate 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 DUE AMOUNT REMITTED CASH RECEtVEO ay DATE PERMIT NO. 4�.J /'y-� �f J /�/ l . Ek I7•I4 rpEV.irwsi ER J O c� 'CJ ! Ory ! II�( /1-06 a`l f