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' APPLICATION FOR PERMIT ' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 4683447 (Complete in Triplicate) fap;licttion Is hereby made to Ban Joaquin County for a permit to construct and/or Install the work heroin described This lication is made in compliance with Sas Joaquia County Ordinance Ko. 549 and 1862 and this Rules and Regulations or Ban quin County �Public Health Services./ Job Address .2 1g- �d, rl��1Tdl's a CIIyS*0 Lot Size/Acreage Lara NamsSteDhYIl t� lPtl-:6-ne_ Add(ass V2-3-7-�CtN1e�_�Lr=,��i�n�SIP7_ Phone 477 S�`-CrQU.N s t/JGo.PATidM,t, 7;Z R i v r l2atc1 ( `) 1 ontracte Address Odes 9,est License No 4-dt,r(.-7a Phone -76-7 YPE OF WELLIPUM-P NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well Cl PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 01Monitoring Well L7 ISTANCE TO NEAREST SEPTIC TANK SEWER LINES Z,S � DISPOSAL FLO N{4 PROP LINE�':Z I 6s FOUNDATION ZQ • AGRICULTURE WELL OTHER WELL_ PITSISUMPS ej�A INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Oie of Well Excavation 6 `f� Dia of Well Casing Oomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing A/,,,C_ Specifications Public KOiher ❑ Oetta Depth of Grout Seal Type of Grout ef"_' r C1 irituatlon Approx Depth ❑ Eastern Surfiee Setif Installed by : vt Work Done U Type of Pump H P State Work Done ell Destruction ❑ Well Diameter Scaling Material i Depth Depth Filler Material i Depth kitailition OF SEPTIC WORK NEW INSTALLATION ❑ REPAIRIADOITION CI DESTRUCTION CI (No septic system permitted if public sewer is available within 200 feet 1 will serve Residence_ Commercial_ Other Number of Erving units Number of bedrooms 1Character of toll to a d4pth of 3 loot. Water table depth EPTIC TANK O Type/Mfo Capacity No Compartments PKG TREATMENT PLT ❑ Method of Disposal Distance to nearest Well Foundation Property Lino REACHING LINE 0 No Ili Length of lines es Totallangth/sue iLTER BED C) Distance to nearest. Well Foundation Property Line EEPAGE PITS 11 Depth Sue Number SUMPS 1=1 Distance to nearest Well Foundation Property Line ISPOSAL PONOS ❑ 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 rule& and rogufauons of the San Joaquin County Home owner or licensed agent's signature certifies the following "I certify that in the perlormance of the work for which this permit is Issued I sheli not j,rnpioy any poraon in such manner as to become subject to workmen's compensation taws of California Contractor's hiring or sub-contracting signature snfles the following 'I certify that in the performance of the worts lot which this permit is issued, I shall employ persons subject to workman s componsa- on taws of California," The applicant rrust u all r q red inspections Complete drawing on reverse side igned7 �/ Title Ci4 n:!iUL� rJ� Date SEMI Ze, /C? 3 1 FOR DEPARTMENT USE ONLY / r Fpplication Accepted by �� '� ' `✓ Date ! ✓ Ara* lt or Grout Inspection by Date Final Inspection by oats JPlo.,l Comments r" r rl r /' /rr ! !„ T_ I ppllcant - Return all copier tot SAN JOAQUIH COUNTY PUBLIC HEALTH SERVICES r ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BQX 2008, STOCKTON. CA 93201 �s o J FEE AMOUNT Dt7ia AM.IOUNT REMITTED H RECEIVED 15Y DATE PERMIT NO INFO r t324rliEV ire61 SL-J r 26