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J APPLICATION l ; SAN JOAQUIN COMMY PUBLIC HEATTH' SESERVICES ENV'R01411ENTAL FMA ,TH DIVISION 445 N SAN_JOAQUIN, PHS (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 2=IT MWIRES 1 YNAR >► nim DATL I SS_tarn (Complete in Triplicate) Aypligetion is hereby mde,to Sas"Joequin county for a permit to construct and/or Install the work herein iDa��- 4011cetion is made in COW11ance vith Sen Joaquin County Ordinance No. 549 and 1862 and the Rules and Re tios� This Joaquin County Public Health,Services. ` San W, i6rd, all ztp Job Address � Citr Lot 31te/Acreage �� Q� r�t.K. Owners None - Address �G Iy r 77 p� Phone fi10!f' e5 tZ Contractor — 1�ddress . License No. Phone + M TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ OESTRUCTIO Out of iftmee pe O PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Nonitoring ViaO 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 fr ❑ Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Wall Carrell Domestic/Private O Gravel Pack O Tracy Type of Casing Specifications I'1 Public n Other n Delta Depth of Grout Seal t'g Type of Grout_W&"A I I Irrigation _Approx. Depth XEastern Surface Sea!Installed by__-Pb( rWIL)d C'r- 1C-UT 1b AR.00t✓ Repair Work Done U Type of Pump H.P. State Work Dane_ C Well Destruction It Wen Diameter Sealing Ilsterial i Depth M W 3 Depth Filler )laterial i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sower is available within 200 test.) Installation will serve: Residence_, Commercial_ Other Number of living units: Number of bedrooms Character of MR to a depth of 3 feet: Water table depth SEPTIC TANK. O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.O Method of Disposal Distance to nearest: Well Foundation Property Lime LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Lime SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: WON Foundation Property Line DISPOSAL PONDS O I hereby certify that 1 hew prepared this application and that the work will be done in accordance with San Joaquin county ordionances, state laws, and rulae and regulations of the San Joaquin County Home owner or licenaad agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued. I shah not employ any person in such maruter as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the following:"1 candy that in the performance of the work for which this permit is issued.I shall employ persons subject to workmen's compenes- tion laws of Califomrda." The applicant ofaired inspractions. Complete drawing verse side. 3 // 1Av. -9 S x Titk: Date. FOR DEPARTMENT USE ONL Application Accepted by Oats Z Area Pit or Grout I -lion by Oate �"''' `-3 Final Inspection Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Snvironmental Health Permit/Services 445 N Ban Joaquin, P O Box 2009, Stkn, OA 95201 / INFO FEE AMOUN�tI�_ AMOUNT REMITTED CASH RECEIVED eY DATE i . all M24Inev.veal � �I D 0 _ � .�•/7/1 IN 14-M V �v