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i APPLICATION ��c t�,� 7�- SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVVIRONRENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 /T: -P 0 BOX 2009, STOCKTON, CA 95201 PERMIT gUIRES 1 YEAR F t N j2ATE IsSjJE (Complete in Triplicate) Application is hereby made to Jan Joaquin County for a permit to construct and/or inot u the work herein described. This Rpplicstion is ts®de In catapliance with San Joaquin County Ordinance No. 549 sad 2862 wttd the Rules and Rggulstione of San Joaquin County Public Health Services. w�� Job Address I-)_i:l 1 SoILA-'r t-� �31Z�/ _ City Lot. Size/Acrcage Owner's Name . _3A B C�BFApRICAC- Address _644-5 jR I Pd:;,hjQ4 ,Phone SRMI'ZCc ContractorzZX1 Address__—_— . _ License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service (fell Cl PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 Nonitortng Well ❑ DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES "- DISPOSAL F _�LO. PROP. LINE I FOUNDATION . _ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Li Industrial Cl Open Bottom ❑Manteca Dia.of Well Excavation Dia. of Well Casing El Oomezliaprivata ❑ Gravel Pack 47 Tracy Type of Casing-__ Specifications CI Public Ill Asher i Fl Delta Depth of Grout Sea.' Typo of Grout I I Irrigation __Approve. Depth/ I I Eastern Swrfncs Saui tnstalled by Repair Work pone Ll Type of PumpY H.P_ _ State Work Done Well Destruction 0 Well Diameter Sealing Haterial i Depth , Depth Biller Xsteria.l i Depth TYPE OF SEPTIC WORK, NEW INSTALLATION 7irR€PAIRIADDIVON I I DESTRUCTION l I Wo septic system permitted it public sewer is available within 200 leat.i Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soitto s depth of 3 feet: m Water table depth SEPTIC TANK ❑ Type/"g Capacity No. Conlpartmenn PKG. TREATMENT PLT,❑ Method of Disposal Distan4e to nearest: Well Faundation Psopany Line LEACHING LINE71, No. iH ength of lines Tpt,l length/aKe FILTER BED 0 Dialn a to nearest: Watt .Foundation Property Line SELEAGE PITS \L01' epth F Size 1 Numb if S istance to nearest: iaeu Foundation Property Lilts DISPOSAL PONDS I hereby eanify that I have pre rad thia application and that the work vmFl be done in accordance with San josquin county ordinances,state laws, and rules and raguirtfans of the San uin County Home owner or Ii @n"d agent's signature certiffi—_aha fotfownrtp:"I cartity that In the performance of the work for which this permit is issued, i than not employ any person in such manner as to become subject in workman's compensation laws of California."Contractor's hitting or sub-contracting signature certifies the(04 uw g:"I certify that in the performance Of the work for which this permit is issued,19MII employ persons subject to workman'a compensa- tion larva of California_" The applicant m1fifall for ad required' 6 rnpleto drawing an reverse side. Title. �,.dwiri Date: FOR DEPARTMENT USE ONLY A &SSILeblitin Acctrmted by /l Date Area/ it r n by ate y Final Inspection by Dat Add" al Comments: IL ri. Appli,•.aut - Return all copies to: San Joaquin County Public Health Services Saviro San meaiJoaquin, p Permit 2009, ces �� � 445 N San Jaequta, P D $oat Z00g, 8tka, CA 65201 �.J FEE AMOUNT Dr1E AMOUNT R#Mil IED K RECEIVED B* A PfRMiT'sid. INFO f / / ' • Eat IYl4 lttEmr,tiwar / ars sr-s sl n/