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APPLICATION SAN JOA UIN COUNTY PUBLIC HEALTH SERVICES -- VIRONMENTAL HEALTH DIVISION 445 N AN JOAQUIN, PHONE (209)468-3420 -- -FO BO% 2009, STOCKTON, CA 95201 ',C # EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) ounty for a permit to construct and/or install the vork herein described. This application to sande in comm once vlth Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban Joaquin County Public Health SeL,rvices. Job Address ART `/` kidt tAl.. FT City&Ma-k-}>v. , Lot Size/Acreage Owner's Name dill nL � Address+ �,F�A�`.i'Cn\� �v`�i�1�L ClC. �.l)hone Contractor ressf�\�e[C2C�Ff�t-11z. 11 _� Liceennse No. Phone `a� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well Ll PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ! Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES �� f DISPOSAL FLDPROP. LINE ,T r FOUNDATION _r2"L_ AGRICULTURE WELL -60d— OTHER WELL & PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation X Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack7 O Tracy Type of Casing_ A IA Specifications —&�A i I'I Public 1-1 Other [I Delta Depth of Grout Seal 39 Type of Grout I I Irrigation __.Approx. Depth al Eastern Surface Seal Installed by 6vjffVf Repair Work Done Ll Type of Pump "IA H.P. gate Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth tT Depth IVIA Filler Material i Depth �� C TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION t I DEST UCTION 1 I No septic system permitted it public sewar is available within 200 feet.) Installation will some: Residents_ Commercial _ Other Number of living units: _ Number of bedrooms Character of sell to a depth of 3 feel: Water table depth ((�� SEPTIC TANK ❑ TVpe/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Lina LEACHING LINE ❑ No. 6 Length of linea Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number p SUMPS LI Distance to nearest: Well Foundation Property Lim DISPOSAL PONDS ❑ 1 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 cenifies the following: "1 certify that in the performance of the work lot 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 subcontracting signature unifies 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 laws of California." The applica"st c Yfor a squired In atti a. Complete drawing on//,rpvans side. '/ Signed Title: Woe. T�EI-/�lA> 9 � Date: 9, FOR DEPARTMENT USE ONLY Application Accepted by G P / /�J ,D/ 6i IJ�)-1,r--dor /IC/7 S Data 6 — 7— Area ©00 X Pit or Grout Inspection by Data Final Inspection by Date Additional Comments: Applicant - Return all copies to: Ban Joaquin County Public Health Services O Environmental Health Permit/Services 2 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE s PERMIT'No. INFO C ENgi.tazv..,a,. P7. gq.h 1k b. �o EN p.ie