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APPLICATION FOR PER1d I T, k .] U SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 r"'\ Py ; (209) 468-3447 ESNIT EXPIRES 1 YEAR rROM DAT;s ISSUED? r (Complete in Triplicate') Application is here made to San J FP by oaqula County for n permit to construct and/or install the work herein described. This application is made in compliance vith San Joaquin County Ordinance No. 549 and;;1862 'aisd the Rules and Regulations of San Joaquin County Public Health Services. Jot)Address B:�gks fa le City G Lot Sine/Acreage � Owner's Name �e aec.�S Ag t!o%A Address _`•O' ?222L (070) 5 16r-L4M' u"+ — Phone 4( "a� i i Contractors Address Z�Z�E: �'�-lre License No. :C-DZ'2-" Phone q4S" TILZ TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION kOut or Service well ❑ 1.1 PUMP INSTALLATION 12 SYSTEM REPAIR C1 ;� OTHER ❑ Monitoring Well G DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE � FOUNDATION AGRICULTURE WELL OTHER WELLM PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFI,CATIONIS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Weil Excavation i Ii Dia. of Weil Casing U Domestic/Private @[Gravel Pack 0 Tracy Type of Casing F4$O ;'90L 11 Specifications 1 © Public CI Other %Delta Depth of Grout Seal 3!1 11 Type of Grout�*^� Cl Irrigation —Approx. Depth Q Eastern Surface Seal Installed by i aM. Repair Work Done ❑ Type of Pump H.P. State Work�Don@_ Wall Destruction ❑ Wall Diameter Sealing Material ii Depth Depth Filler Material i Depth �M TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADOITION 0 DESTRUCTION U (No septic system permitted if public sewer is availih le within 200 feet.) n Installation will serve: Residence—... Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: 1Water table depth SEPTIC TANK D Type/Mfg Capacity ..]No. Compartments PKG. TREATMENT PLT.❑ �Methodl of Disposal Distance to nearest: Weil Foundation. Prepeky Line LEACHING LINE 0 No. b Length of lines Total°length/size FILTER BED © Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 1 Depth Size Number IM ............... SUMPS 0 Dis-a ' Prop to nearest• Well Foundation erty Lute _ DISPOSAL PONDS r ❑ ; I hereby certify that I have prepared this application and that the work willrules and regulations of the San Joaquin County be done in accordance with San Joaquin county ordinances, stale laws, and .- . .•. - _ . - ._,....,,. s. ... _ ._ . _..__....... .. .. ._ .. dome owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shale not employ any person in such manner as to become subject to workman's Compensation taw$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, l shall employ persons subject to workman's compensa- ilon laws of California." • ' -.--- - - _... .. .. The appy nt at call for alt red' spections..Complete drawing on reverse side. :{ Z Signed Title:Niru -� i Date: FOR DEPARTMENT USE ONLY ' M s Application Accepted by Date! Ii Area 4 Pit or Grout Inspection by Date V `L Final Inspection by; "` Data Additional Comments: it Applicant - Return 911 copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERVLT 8911viCEB Ih �(� 443 H SAH JOAQUIN, P 0 BOX 2008 TON,, CA 85201 ` 00 ` i lFEO AMOUNT DUE AMOUNT REMITTEt7 CASH >l EO t!Y �I LATE PEAMIT'NO. r3.2+ulev.1111 s,