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+ APPLICATION � SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (2W468-34210 P O BOX 2009, STOCKTON, SCA 95201 PERMIT EXPIRES 1 YEAR FROM DATEIIISSUID (Complete in Triplicate) "" li 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 with San Joaquin County Ordinance No. 549 and A§2 and the Rules and Re tions of San i�it Joaquin County Public Health Services. �I {Il--0>6 — o(z �/t Cit II Lot Sim-,/Acreage rif Job Address y Owner's Name 64 Address El Phone I' 730 rrton� ur�(o''cr, 7 .SB y. Contractor Address icen3e No. Phoney TYPE OF WELL/PUMP: NEW ELL © f,.t; WELL REPLACEMENT nlf 11 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTAIX LATION �•"' } SYSTE REPAIR ❑ii /�N 1L,�THER L� Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK �� SEWERYLINEf3g' DISPOSAL FLD. PROP. LINE FOUNDATION � 4AGRICWLfURE ELL +,�� OTHf R WELL PITS/SUMPS.(:�A INTENDED USE TYPE OF WELL PROBLEM AREA" CONSTRUCTION SPECIFICATIONS L-} Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation :I Dia. of Well Casing * Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing_ �e !! Specifications I'1 Public f-1 Other ill Delta Depth of Grout Seal Type of Grout I i Irrigation __,Approx. Depth I I Eastern Surface Seat Installed)by Repair Work Done [J Type of Pump H,P. _—I State Work Done Well Destruction ❑ V�lel}Diameter .e Seali MateFial b Depth IM _ FI11 N:e ia1 & Depth TYPE OF SEPTIC WORK; I. TA,L. TION I I REPAtRlADDITt ty' I ,DESTRUCTION I I Wo septic system permitted if public sewer is • �. available within 200 feel-I Installation will serve: Resik�ce-" Commercial Other �* � I Number of living units: �. —Numtiertof bedrooms i Character of soil to a depth of 3 feet-` "- " Water table depth SEPTIC TANK ❑ Type/Mfg Capacity �I I No. Compartments PKG. TREATMENT PLT. ❑ i� Method of Disposal Distance to nearest: Wel! Foundation I, Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line w SEEPAGE PITS 11 Depth Size Number SUMPS Lt 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 owner or licensed agent's signature certifies Ihe.following; "I certify that in the perfor lance of the work for which this permit is issued, I shall not r employ any person in such manner as to become subject to workman's compensation laws of ICalifornra." Contractor's hiring or subcontracting signature canifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa- �. tion laws of California." The applicant mus it required 'ns ns. Complete drawing on reverse side. I Signed t Title. V.�I .I; Date: FOR DEPARTMENT USE ONLY�I I Application Accepted by pate Area r ! I! f Pit or Grout Inspection by Date � .Final Inspection by '! Date f Additional Comments: £ �I Applicant - Return all copies to: San Joaquin County Public Hcalth Nervices Environmental Health Permit/Servilces ;;I 445 N San Joaquin, P O Box 2009, i'IStkn, GA 95201FEE r I� INFO AMOUNT RUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. - EH EMtl.2aIREV.1in5J t6-3s / -9 II it