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APPLICATION FOR PERNI'. L SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES .r . ENVIRONMENTAL HEALTH DIVISION . P O BOX 2009, STOCKTON, CA 95201 (209) 468-344?- MAR (Complete in Triplicate) � Application is hereby,idade to San Joaquin County fora permit to construct and/or instAit the work herein described. This application is made ij compliance with San 3oaquin County Ordinance No. 549 and 1962 and the Rules and Regulations of San Joaquin County PubliclHealth Services. r' / Job Address d 05'. �I. �or-q p(� .,.S City o Lot Size/Acreage QJ$� wtr^e-C Owner's Name �XX o�'1 C-C r>7.44 �, U S A.Address ��4 0 CI4 �c4. s�I�57� Cosr c Phone Com+' 9�1S2y-�D32 '1 ConlractorLd�t� a2mka r^. f' Address,3233 F+x a IQl �arf<�re�r+cfo.el�wtttitse No.G$T-S'3"yg79 Phonr(9/ 3r-7-77,6I TYPE OF WELL/PUMP: ; ' NEW WELL CI WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well E)PUMP INSTALLATION C SYSTEM REPAIR C1 8sr%n4ATHER� Monitoring 51e11 U DISTANCE TO NEAREST:.?SEPTIC TANK SEWER LINES DISPOSAL FLOrJ PROP. LINE !FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n industrial ❑ Open Bottom ❑ Manteca Dia. oi-kAAA-Geeeaet+en r"' - Ir ` fi}Dia. of Well Casing K Domesticl Private ❑ Gravel Pack ❑ Tracy Type of Casing 1 - or Specifications A/W 11 © Public 1? Other5_.d.Fv,Virg ❑ Oeita Depth of Grout Seal // v�'h_ 7 s/ rr• G �7 ype of Grout Cl Irnuation M Aoprox. Depth . 1] Eastern Surface Seal Installed by&��rt��Zr�►wf (��>s t Repair Work Done CO Type of Pump H.P. State Work Done _ Wall Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: -;NEW INSTALLATION 13 AEPAiR/ACWTiON M DESTRUCTION u (No septic system permitted it public sower is available within 200 feet.) Installation will servo: Residence — Commercial Other Number of living units: Number of bedrooms Character of sail to a depth of 3 feet: Water table depth . SEPTIC TANK ❑i Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. M.,: Method of Di spasal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. $ Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line c\ SEEPAGE PITS 1 1'1I Depth Sire Number }1 SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑iCi C 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 thel.San Joaquin County Home owner or licensed agBrit's signature cent ies 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 fAanner as to become subject to workman's compensation laws of Cafifornis." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the pertofmance of the work for which this permit is issued, I shall employ persona subject to workman's compansa- tion laws of California." The applicM,�iall nil requir ctions. Complete drawing on reverse side, Signed X0Title: �T �/�t� Date: l I"I F EPARTMENT USE ONLY Application Accepted by Date "' �` / Area Pit or Grout Inspection by Date Final Inspection by pate Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 Y SAN JOAQUIN, P O BOX 2009, STUCKTON, CA 95201 I'I i NFO FEEAMOVNT ot1E AMOUNT REMITTED [ASFf RECEIVED BY DATE PERMIT NO. r�� Ek 17-74 imEY. •si � L� � � l ,�