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I. APPLICATION FAR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ^, ENVIRONMENTAL HEALTH DIVISION : P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 REMIT EXPIRES I YEAR PROM DATE IShJUM (Complete in Triplicate) Application is hereby made,Uo San Joaquin County for a permit to construct and/or install the work herein described. This application is snide in compliance with San Joaquin County Ordinance No. 5119 and 1862 and the Rules and Regulations of San " Joaquin County Public Health Services. / �� Job Address �0 i S r �"�"��"i.�.._.....---- City r Lot Size/Acreage Owner's Name -�t-I"``+tL�. Il �� w �'�"��Lress C/of L)✓/Q �� Phone ��o� �8 1,-3 Contractor t'VC (� (�"S'ddress 10 d- '60)e 2,57-05 License No. �y 33 /? Phone 4/4'x'ly6 3 TYPE OF WELL/PUMP: P NEW WELL CI WELL REPLACEMENT [D DESTRUCTION 0 Out of Service Well 7- PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack C] Tracy Type of Casing Specifications ❑ Public [1 Other ❑ Delta Depth of Grout Seal Type of Grout Iv U frnoation _ �.Appfox. Depth 0 Eastern Surface Seal Installed by [/1 Repair Work Done U Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material L Depth Depth ' Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION M DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve:. Residence^ Commercial— Other Number of living units: Number of bedrooms Charactef of$oil to a depth of 3 fest: ^" Water table depth SEPTIC TANK. O Typo/Mfg Capacity -- - No. Compartments PKG: TREATMENT PLT. 0 I � Method of Disposal Distance to nearest: Well Foundation Property Line f y LEACHING LINE ❑ No. & Length of lines ;` I Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line ' SEEPAGE PITS 11 Depth Sire Lk *` Number SUMPS 1_1 Distance to nearest: Well Foundation t Property Line , DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with'Sin Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agents signature certifies the following: "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 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 persons subject to workman's compensa- tion laws of California." The applicant muy 5all for all required inspections, Complete drawing on reverse side'. Signed X Title: Date: C/! 3 0/4 0 OR DEPARTMENT USE ONLY Application Accepted by Date Area / Pit or Grout Inspection by ate Final Inspection by Data) ( 0 Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O Box 2008, STOCKTON, CA 88201 INFO �jAMOUNT DUE AMOUNT REMITTED CASH RECEIVED PATE PERMI7'NO. . EN 13-24101EV,i/M6i fm r