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!f � Y APPLICATION FOR PERMIT SAN JOAQ[)IN COUNTY PUBLIC HEALTH SERVICES 1 } I: ENVIRONMENTAL HEALTH DIVISION it P O BOX 2009; 'BTOCSTON, CA 95201 (209) 468 -3447 it (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 cccWliance With San Joaquin Co ty Ordinan a No. 549 and 1862 and the Rules sad Regulations of San Joaquin County Public Health Services. -770 Z� j 2j Job Address - -- City Lot Size/Acreage {'��----- -- Owner's Na ms�^'+ I� !f Address 5'" i4 -14pin e-6i "DR r✓�'. . }Phone 9/4," 9 22-ow� Cbnlractor -n OSS"RftAddress �-t��¢�'� LO License No.5Q p- �` Phone 7`IS-�o`I TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n- DESTRUCTION ❑ Out of Seryice Well Irl, PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINErLor."_ } FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ._ INTENDED USE TY OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT10NS [I Industrial Open Bottom ❑ Manteca Dia. of Well Excav n Dia, of Well Casing LH-iD`omesfic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Q Public 1-1 Other ❑ Delta Depth of Grout Seal or,r Type of Grout r CJ Irrigation t - Approx. Depth0 Eastern Surface Seal Installed by Repair Work Done U Type of Pump c2 H.P. 1D State Work Done _ '! Wall Destruction ❑ Well Diemetar Sealing Material A Depth 4 w. Depth 'I Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 'REPAIR/ADDITION C.l DESTRUCTION,G (No septic system permitted if public sewer is r --available within 200 feet.) Installation will serve: Residence .._ Commercial Other - r Numb-iiof living units: [;Number of bedrooms Character of soil to a depth of 3.feet: Water table depth SEPTIC TANK ❑ T l YPe/Mfg '� Capacity No. Compartments PKG. TREATMENT PLT..0 II Method of Disposal Distance to nearest: I Well Foundation Property Line LEACHING LINE ❑ No. 'b Length of lines Total length/size N FILTER BED ❑ Distance to nearest: Well Foundation Property Line F SEEPAGE PITS II 'k Depth Size Number SUMPS r Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 ountyHome 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 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 compen tion laws of California." !I. The a`pplic nt cats far q ired inspections. Complete drawing on reverse side, p ' i Si9� I Title: � fUA-., Data: FOR DEPARTMENT USE ONLY 1> Applidation Accepted by Date O " 2 Are,, Pit or t Inspection by Date.2-Final Inspection by G;+r��/! dl-� ata Additional Comments: :i Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES (� ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES t 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 INFO AMOVNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PE NO. 777-5 05 . EN t3-24 IREV.i n p EN 114'.20 'l