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APPLICATION SR # SAN JOAQUCOUNTY PUBLIC HEALTH SERVICES AID # 0,;� ONMENTAL HEALTH DIVISION 445 N SA JOAQUIN, PHONE (209)468-3420 FAC C # % 2009, STOCKTON, CA 95201 n �' tI/ # �J 1 IRES 1 YEAR VD"U DATE ISSUED Y `7 Complete in Triplicate) Application Is hereby a ty for a permit to construct and/or install the vork herein described. This application is made in compliance with San Joaquin County Or inance No. 49 d 1862 and the Rules and Regulations of San Joaquin County Public Health Service��y� Job Address /'�s f S1 VE -01P 416 PE44�2n -_ City �� Lot Size/Acreage ��{ �; S. OF f3 uO12fE�Z Owner's Name Address �� MOR Ml- /"/��A JAI Phone ��9f��f / Contractor C Address __L«_�_. f•��GLSdL— License No. Phone -y�9S/� TYPE OF WELL/PUMP NEW WELL O WELL REPLACEMENT 1-1 DESTRUCTION ❑ Out of Service Well Ll PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER O Monitoring Well 0 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 ] Industrial U Open Bottom Cl Manteca Dia of Well Excavation Dia. of Well Casing 1 Domestic/Private Cl Gravel Pack Cl Tracy Type of Casing____— Specifications I'1 Public 11 Other I I Delta Depth of Grout Seal Type of Grout I Irr.uatron _ Aplvox. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. _ __..—._.— State Work Done — Well Destruction D Well Diameter Sealing Material i Depth Depth Filler Material fi Depth TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 111No septic system permitted if public sawer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other r� Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ---______ _.___— —Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well Foundation Property Line y LEACHING LINE L-) No. 8 Length of lines __ _ _ Total length/size FILTER BED CI Distance to nearest: Well _ _ Foundation Property Line SEEPAGE PITS 11 pth Size ___ Number SUMPS 1.1 Is ce to nearest: Well Foundation _ Property Line DISPOSAL PONDS D r 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 wfes and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following. ''I certify that in the 0erlormance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman'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 compensa tion laves of Califor la." The appficant call for at re0 inspections. Complete drawing on reverse side;. re ] Signed X Title: vie I�rT Date: 1' �/� FO DEPA TMENT SE ONLY Application Accepted by -- _ Date 1� Ar Pit or Grout Inspection by ,p Date / Final Inspection b Date�� Additional Comments: 0��6��E'of�F�TiGc4� Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 22 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 • � FEE AMOUNT DUE AMOUNT REMIJIP0 RECEIVED BY DATE PERMIT'NO. INFO CASH . EH 13.24 If1EV.r 1"Sr 'K 1 J�'- �+C l3 23 00/1 EM t4 2a —