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APPLICATION AR 7��41- /.o k� tiud_r code osh # .. ^r Pf 3 r,. tt.,l,',SAN JOAQUIN COUNTY PUBLIC HE CES 44 g re ENVIRONMENTAL HEALTH DIVI � ___ C o� ooS¢d Lc a 445 N SAN JOAQUIN, PHONE (209, 3$20 P O BOX 2009 STOCKTON, CA 1# 7/zr/qY `) ' A'`I SAN JOAQTIT? I CO L1I`TTY -PUBLIC IITJ. Ma RES 1 YEAR FROM DArl EI'I�9 ENVIRONPAENI'ALHEAI,TII1)!VISION (Complete in Triplicate APPli ♦ cBogA.iNS6Fr County for a permit to construct and/or install the work herein described. This app111LIo4ilaAilel� n Joaquin County p dinance No. 549 and 1862 and the Rules and Regulations of San Joaquin Count Public Health Services. t q y 5 lL �6f �/a acJc // a 'fe� Job Address �3a•C 4/I-l. /?C/= !J` v ! 7 city�� / '� Lot Size/Acreage nu Owner's Name /I �i( /7fLQ/L>�i11 /Pdf . Phone z Address Tf' //-- Cont,actor � ' �z Address �� 7 2. :VJ� Q- License No. 13 Phone 57' / TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well U DISTANCE TO NEAREST: SEPTIC TANK nnn?� SEWER LINES 50 r DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS o1Esz• CI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation / Dia. of Well Casing ,/I (.I Domestic/Private Gravel Pack ❑ Tracy Type of Casing_ SLP G Specilicationa IXf Public 1-1 Ot�r Ll Delta Depth of Grout Seal r� z Type of Groullt ��r�[�.�"11 I I Irrigation 1WAppfox. Depth I I Eastern Surface Seal Installed by l�t(IIF�IJ G (F - Repair Work Done U Type of Pump H.P. "_._ State Work Done _ 1, Well Destruction ❑ Well Diameter Sealing Material i Depth (''t /l0 -2.Osz lu — h pe Filler Material a Depth TYPE OF SEPTIC WO K: NEW INSTALLATION I I REPAIR/A UCTION I I (No septic system permitted if public sewer is RECEIVED available within 200 feet.1 Installation will serve: Residence_ Commercial_ Other (r� Number of living units: _ Number of bedrooms ------My 1 1 1994 x17111' Character of soil to a depth of 3 feet: CAA' InAnilCOUNTY ipiI Water table depth SEPTIC TANK ❑ Type/Mfg PUBLIC NFAI Tt"F# IIGEg No. Compartments + PKG. TREATMENT PLT. ❑ ENVIRONMENTAL HEALTH DIVISION Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length or lines Total length/size FILTER BED - 0 Distance to nearest: Well Foundation Property Line IP SEEPAGE PITS 11 Depth Size Number SUMPS LI 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 regulatioAs of the San Joaquin County Home 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 workmen'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 compenss tion laws of Calif "Io The applicant u t call for all required .ls�,actions. Complete�dipwinng on fa arse sid ' / Signed X / _�G�itll�. Date: i� ��/-C7l`�" ! ! FOR [1/EPA MENT USE ONLY Application Accepted by 1 i Date /ifArea Z '� Pit or Grout Inspection by ate Final Inspection by Deta Zf Q 7/z(W- F•+rz1.rP L(/e!( �o (re. sy/fiaX l `/-'�..t arras�-4� `EC,sf' A-(#- •'�.� � �-d Additional Comments: goo O z e2WE4 J afid- w"..s .,s c o— fp,•,e vast. Applicant - Return all copieloto: San quin County P is Health Services >,o �� w/C,y�"v- _ (_v-ell f0 Environmental Health Permit/Services ft -7q' f/o'if' .,y. X11 F��• 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 C 2'�-uG'r�tsl 0✓�r E AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PER4I7'NO. • E14 IYIREV.,/n sl FH to 7eN