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AF'1'1,1UA'1'1UN FOR YEltM]7' SAN wAQUIN COUNTY PUBLIC HEALTH 1' ICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201. (209) 468-3447 R ERQM DATE ISSUED (Complete in Triplicate) Application is hereby tswde to Sari Joaquin County fora application to made in emwilance vith San Joaquin County yOrdinancemit to nNo. 549:andstruct o1862aand lthe eRules and vork eRegulations of Sanin described. s Joaquin County Public Health Services, f��, i Job Address S '1_ E• A e Ae-1/4 5,) � i~ City., -rf Lot Site/Acreage F,�rC'rfFlf30�,C Owner's Name Address �. d a Phone ?Z` Py`'G 3S3 Contractor Tr- Pip/1 1_/<, Address 34 — E�lrr C� - ± License No. S•1`J�} Phone `1l(� � L /- TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT C Cl . DESTRUCTION Cl Out or Service Well ❑ PUNIP INSTALLATION ❑ SYSTEM REPAIR El OTHER Q Honitoring Well 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 rt (.1 Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation— -Y Dia- of Well Casing L g Oomes[ic/Private XGravei Pacts forTrac. v+t y Type of Casing--F V_t!, Specifications � D Public i.l Other U Delta Depth of Grow Seal I S_ r Type of Grout /�r` W#,II'D"'eas"toruction az11Approa. Depth U Eastern Surface Seal installed bypair Wrk Done 0 Type of Pump H,P, _____IlStats Work Donq D Well Diameter Sealing Material i Depth i1 Lt r Tn 2-7-- Depth 4 Depth Piller Material A Depth x 15 Tv- 1W �4rLD t TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION M DESTRUCTION CI iNo septic system permitted it public sewer is €} II available within 200 feel.l .. Installation will serve: Residence __ Commercial„____, Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet. - _ Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments €' PKG. TREATMENT PLT. I_l Method of Disposal Distance to nearest: Well Foundation Property Line LEACWNG LINE Ll No. 6 Length of lines _ Total length/size FILTER BED ❑ Distance to nearest: Well _—_ Foundation Property Line Il i SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Ij Property Line LDISPOSAL PONDS ClI 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 1� Home owner or licensed agent's signature certifies the following '.'I certify that in the pariormance of the work for which this permit is issued. I shall not L#^ employ any person in such manner as to become subeel to workmen's compensation laws of felifornin " Contractor's hiring or stub-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 eppli uuatl for All r u ed inspections. Complete drawing on averse side.'1 L r. X Signed X �? -s Title: v {' /4u Date: Z r� FOR A DEPARTMENT USE ONLY 4-0 licstien Accepted DP P by -- Date ea i y. Date Final Inspection IIb Pit or Grout Inspection by Date tZ�of Additional Comments: f Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC 11HALTH SERVICES r ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES Z9U+� 445 N SAN JOAQUIN, Y O BOX 2009, STOCKTON, CA 95201 FEE AMOUNT ptiF AMOONT nEMIt TED INFO n CASH R EIVEp BY DATE PERMIT NO. fH :4.7s —UUU-- - __._- -z -p I� I {