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' APPLICATION ' SAN JOAQUIN COUNTY PUBLIC HEAHT WICES ENVIROXWOTAL HEALTH DI I 445 N SAN JOAQUIN, PHONE (20 )1"-2--2420 P O BOX 2009, STOCK'TON, C ••� P=IT EXPIRES 1 YEAR nom D ...•■ (Complete in Triplica e Application is hereby inside to San Joaquin County for a permit to construct an application is made in oozF'liance with San Joaquin County ordinance No. 549 an and the Rules and Ae`vlations of San Joaquin County Public Health Services. r Job Address 1 7ti f Fr° R d id ll Ciry L_a:L�1 /7 Lot Size/Acrear e owner's Name ��,k I� �� - Address 1 t� 1 �.1, 1�1f Phane a ` �? '�'•Address d i,�'G�? 11 �d,I License Na. Phone 073 .-��/ Contractor S f; ^ �------- TYPE OF WELLIPUMP: NEW WELL O WELL REPLACEMENT C) DESTRUCTION D out of Service Well Gl PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER p Monitoring Well � DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLS . PROP. LINE FOUNDATION _. AGRICULTURE WELL OTHER WELL„_______ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial D Open Bottom ❑ Manteca Dis, of Well Excavation Dia. of Well Casing t CI Domes0clPrivate 0 Gravel Pack O Tracy Type of teasing_ Specifications Ci' Public EI Other n Deita Depth of Grout Seal Type of Grout- _ I i Irrigation —Approx, Depth I I Eastern Surface Seal installed by ' Repair Work Done U Type of Pump H.P- ____ State Work Done Well Destruction 0 Well Diameter Sealing Material L Depth Depth Filler Material & Depth TYPE OF SEPTIC W001C NEW INSTALLATION 11 REPAIR/ADMTSON 1 1 DEST%JCTION 1 1 INo septic syste n�pitted`prrblic is available Cly" eet.l In tarzio twill1ser." ,P`Rade...�' Commercial_Other Number of living units: Number of bedrooms t Character of son to a depth of 3 feet: - __ We r table depth SEPTIC TANK 0 Type/Mfg Capecity— No Compartments PKG.TREATMENT PLT.0 M thud of Disposal Distance to nearest: Well_ Foundation_ Props Line LEACHING LINE 0 No. &Length of lines _ - - - - Total length/sire FILTER BED 0 Distance to nearest: Well Foundation__ Propery Line I JN SEEPAGE PITS I I Depth 'Size a Number / SUMPS Li Oistance to nearest: Well— Foundation P►4gas r / DISPOSAL PONDS Q 6 ' I hereby certify that I have prepared this application and that the work will be done in accordance with San, aquin county ordinaccs, eta laws, and . rules and regulations of the San Joacmin County Home owner or licensed a®ant°a signPfure certifies the following: "I certify that in the performance of the work or which this permit' issued, i shall of employ any parson in such manner as to become subject to workman's compensation laws of fielifor hiring or sub-contracting si ature certifies the following:"I certify that in the performance of the work for which this' permit is issued, I shall employ pe n>t bject to work&.sn's mpsnsa- tion lows of California•°° S The applicaronu tt call dor old. ulr rn$ ctions. Complete drawing on reverse sid )I.,- FOR � Signed 116M__"YI"�_ Title: ��f° Date: ) ' FOR DEPARTMENT USE ONLY / Application Accepted by Date / Area , ' Pk or Grout lrspection by pate nal tnSpec by Dave Adolanal Comments: • S7 Applicant - Return all copies to: San Joaquin County Pu c Health Services lVar"f'o ' Environmental Health Permit/Services / 9.45 N San Joaquin, P D Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNTREM17VED � H RECEIVED 9Y DATE PERMIT'NO, INFOl„ '^ E"139 IREV,s/i+m Ah Ebt 04.90 l