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APPLICATION ' SAN JOAQUIN COUNTY PUBLIC HEALTH S1ERVi��rS / � ENVIRONMENTAL HEALTH AIVISI 445 N SAN JOAQUIN, PHONE (209)46 _3e,0,µµ P 0 BOX 2009, STOCKTON, CA 95 0�1' .0 it PERMIT E%PIR S 1 YEAR FROM DATE TP S=1—�` (Complete in Triplicate) Application is hereby made to San Joaqulu County for a permit to construct and/or install the work herein described. This application to bade in compliance with also Joaquin Coty Ordinance No. 549 and 862 and the Rules and Regulations of San Joaquin County Public Health Services. t//S -f ' Job Address q'2_ 1 f Crew�JGy�'----. Lot Size/Acreage Owner's Name '- Address ��"""' Phona l._,J_L— 6 +'s f Contractor •'� �+ r Address 70 J ! __,_ License No, fj Phone qY F-02- TYPE OF WELL/PUMP: I NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION C SYSTEM REPAIR CI OTHER 0 MorAtoring Well LT DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESDISPOSAL FLO. PROP. UNE FOUNDATION AGRICULTURE WEL OTHER WELL PITS1 SUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONST CTION SPECIFICATIONS ' CI Industnaf L Open Sottom Cl Manteca Ola i elf Excavation Dia. 01 We" N Domeftic/Private ❑ Gravel Pack 0 Tracy ype f Casing__._,__-,��Ta�a�,�`j�s�e'1 Y✓ I'! Public Cl Other i-` Delta Dept of Grout Sea! I I In.9W100 _-_ Approx. Depth I I Eastern Surf ce Seal Installed by •'� �1Ru Repair Work Done ❑ Type of Pump H.P. _ Stale Work Well Destruction d Well Diameter Sealing Material k Depth SA yix 2S0,RvtC�g Depth _____ / Filler Material A Depth 1,TH Stµ ' TYPE OF SEPTIC WORK: NEW INSTALLATION Ilr REPAIR!ADOITMN 1 1 DESTRUCTION I I INor{9p,P( i eli red if public jewel is � a, within wwithin TOO Poee.l Installation will serve: Residence Commercial '/Vryier Number of living units: .__ Number of bedrooms��_ p CRarectw of&ON to a depth of 3 leer: Water table depth SEPTIC TANK 0 Type/Mfg , v t� _ apacrty No. Compartments i\ PKC. TREATMENT PLT.❑ Method of Disecrijil (� ' Distance to nearest: Well--.✓(-fes)-��-Jffoundation t014- Property Line 0 LT � LEACKING LINE D No. & Length of lines _ ToAl liengthisize FILTER BED ❑ Distance to nearest: Well FounaalProperty Line . ' SEEPAGE PITS 1 I Depth Well SUMPS lJ Distance to nearest: Well Foundation o Property Lina �, DISPOSAL PONDS ❑ I hereby cenify 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 Nome,owner or licensed agane's signature parties the following: "1 cenify that in the periormance of the work for which This permit is issued,I shall not ' employ any person in such mannel as to become subject to workman's compensation laws of California."Contractor's hiring at sub-contracting signature certifies the lollowing: "I cenify!hal In the performance of tha work for which this permit is issued,1 oder employ persona subject to workman's compansa lion lawn of California." " The applicant mu eq.for at sed in lana. Complete drawing on reverse sale. ` Signed t7 TitleDate: FOR DEPARTMENT USE ONLY / Application Accepted by C Cats I �' S �'� iso Pit or Grout Impeclion by Date _ Final Inspection by Data �l Additional Commanea: Appitaant - Return alt copies to: San Joaquin County Public Health Services Enviroamentel Health Permit/Servf cis 'I iL� 44.r. N San Jazqutr., p 0 Box 2009, Stkn, !;d Fg 5201 n 7 JC) C)(3 S1) ° FEE AMOUNT DUE AMOUNT REMITTED Ck RECEIVED BY DATE PERMIT NO. sIN40 (AS7N EN t/Ia IREV.i:xsr /\/f� J L