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� APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH RVICES �y ENVIRONMENTAL HEALTH DIVISION .�a� l445 N SAN JOAQUIN, PHONE (209)468-3420 �� El��' BO% 2009, STOCKTON, ..-CA 95201-- � Ci�ji VE® _ __ . . .�- _ _ - APR �. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JO 9 1993 (Complete in Triplicate) PU(�gpp�I�hh'eeCrrH aT COONry Application is hereby made to San Joaquin County for a permit to construct and/or install thfe'iJdr' Ni;4i � This application is made in compliance vith San Joaquin Count Ordinance No. 5hg and 1862 and the Rules and Re >yj� an Joaquin County Public Health Services._ Lot Size/Acreage / tC�t!// /) Re Job Address Q n�i d f C i I y + r� iAJ C7 , }� Owner's Name Cl �� Address / £' / -7z A 1 4 hone Contractor S Hddress�[l •�/t9e s.r�+ K License No,�`�!f�`�_Phone YPE OF WELL/PUM?: NEW WELL ❑ WELL REPLA )ENT /� DESTRUCTION Cl Out of Service Nell ❑ PUMP INSTALLATION C1 SYSTEM REPAIR ❑�•y� T ER MPnitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES I DISPOSAL FLD. OP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial ❑ Open Bottom d Manteca Dia. of Well Excavation Dia. of Well Casing f.1 Domestic/Private ❑ Gravel Pack7 ❑ TracyType of Casing_ specifications 1'I Public Cl Other n Delta Depth of Grout Seal Type of Grout 1.1'ir6oation —Approx. Depth I I Eastern Surface Seat Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Sealing Material & Depth Well Destruction ❑ Well Diameter n & Filler Material Depth Depth p TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) �l Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING UNE ❑ No. & Length of.lines Total length/size FILTER BED C1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 the San Joaquin County Home owner or licensed agent's iignature certifies the following: "I conity that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workmen'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 laws of California." The applicant must c for all uired inspections. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY jJ Application Accepted by Date Area Area 9 Pit or Grout Inspection by Date Final Inspection by Date -�3 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services 445 N San Health Permit/Services \ �/ 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. INFO /' . EK 13.24 trtEY. i M 51 -�, `l'1 ��(� EK t4-2e