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Ij __ �- APPLICATION FOR PERMIT �rt..�iAQUIN. COUNT ".., SAN PUBLIC HEA.LTH �RVIC i i �;"/ ;psi ENV I RONYIIITAL HEALTH DIVISION ��'— 445 N SAN'`JOAQUIN, PHONE (209)468-342 P O BOX 2009, STOCKTON, CA 95201 PERI[ T I RBS r FR M D T (Complete in Triplicate) NV G ETA Ai_ H P"" IT�S RV This Application is hereby Isade to &aa Joaquin County for n permit to construct and/or install the vont ere n Yibed. di application is made in compliance vith San Joaquin County Or Joaquin 549 and 18(12 and the Rules and Regulations of San Joaquin County Public Health services. . 101 3 We f I Tr T/;r_r 7 City j Lot Size/Acreage Job Address nn G J, 0(= T��.AC Address 57 Z-0 -Tits,( t�,L v D, TI�r4�- Phone ZO 36 <{ZO Owne('s Name C G0.707) 71q Contracts . 3+FS Address 387/ as r`r <lE License No�J t/ O Y(O Pnone DESTRUCTION T WELL REPLACEMENT {'1 :❑ Out of Berries Well 0TYPE OF WE4L/PUMP: NEW WELL Cl OTHER C1Monitoring Well PUMP INSTALLATION 0 SYS'rEM REPAIR D DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES _ DISPOSAL FLO. PROP. LINE FOUNDATION :'AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Z I BCH c Ll Industrial O Open Bottom ❑ Manteca din. of Walt Eaca?V C Dia, of Well Casing Soocifications fl Domestic/Private Gravel Pack ❑ Tracy Type of Casing I"1 Public f"] 011ier r7 Delta Depth of Grout Seal -7 i ' 1 Type of Grout NC,47-'EL-'y EV I I irrigation Approrr. Depth I I Eastern Surface Seal Installed by SQlLS �x Guru,+-rio,✓ S��vICF3 C AJ 1A 7 Repair Work Done U Type of Pump — H.P. N4-- Stats Work Oone"4 ' ror/ . Well Destruction ❑ Well Diameter, -lnlL'H Sealing Material & Depth fRQV� '-� 3 Depth v z� FEES Tiller Material i Depth 3 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION I I (No septic system permitted if public sewer is l available within 200 loot.) Installation will sere: Residence— Commercial Other Number of living units: Number of bedrooms Water table depth Character of soli to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg capacity_ No. Compartments PKG, TREATMENT Method of Disposal PLT.L T. ❑ Distance to nearest: Well Fovndstion Property Line a LEACHING LINE Cl No. 6 Length of lines Total length/sire FILTER BED ❑ Distance to nearest: wall Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest:: well Foundation Property Line DISPOSAL PONDS ❑ I hereby carvfy 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 regutatiorn of the San Joaquin CourttY I shall not H owner or licensed nt's signature certifies the following: -I certify that in the performance of the work for which this permit is traced. Home aW rectors Kirin or sub-contacting signature employ any portion in such manner as to become subject to workmen's compensation taws of California." Cont 0 certifies the following:"I certify that in the performance of the work for which this permit is imued, I shall employ persons subject to workman's compems- tion laws of California." The applicant must CA for all r aired inspections. Complete drawing on reverse side. q Title: "GIA CSF Date. Signed FOR DEPARTMENT USE ONLY �t p Date Zt 1� Area �•�yll• Application Accepted by Ld 1c- Date Li 22 s incl Inspection by M Date Pk or Grout Impaction by Additional Comments: A"`�jl f •t! �=—�` r �� 'J Applicant - Return all Vies to: San Joaquin County Public Health Services Environmental Health Permit/Services Q [ 445 N San Joaquin, P U Box 2009, Stkn, CA 95201 J K RECEIVED By DATE PERMIT NO. INFO AMOUNT DUE AMOUNT REMITTED riSN :�FT �� E . EM 13-74 IFIEV, KA 1