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APPLICATION FOR PERIL I T "' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES jig ' ENVIRONMENTAL HEALTH DIVISION �� P 0 BOX 2009., STOCKTON, CA 95201 Ei°��Vl� r� 2 8 1991 (209) 468-3447 p1MENTAL HCAL.TH YEAR PROLDATE ISSUBP A +�Fv'r�F/moi {illi: (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance-with Sun Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address J City„ Lot Size/Acreage Owner's Name Address -�'fss. „• Phone Contractor Address �3i . a�C!(G�"g�ta- .�'_—�" License lY -Sr few Phone - TYPE OF WELL/PUMP: NEW WELL �❑ WELL REPLACEMENT `❑ DESTRUCTION ❑ Out of Sprvice Stell ❑ PUMP INSTALLATION- SYSTEM REPAIR Cr_ OTHER ❑ Monitoring Well n DISTANCE TO NEAREST: SEPTICTANK "A SEWER LINES DISPOSAL FLO. PR LINE D'A FOUNFION AGRICULTURE WELL OTHER WELL �5/ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F1 Industrial ❑ Open Bottom ❑ Manteca Oia. of Well Excavation Dia, of Well Casing `EJ 0stic/Private C1 Gravel Pack 0 Tracy Type of Casing Specifications 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irnpation / Approx. Depth ❑ Eastern Surface Seul Installed by Repair Work Done <e�`-Typ_e'of,Pump: HJPyP1r State Work Done G Well Destruction ❑ W8$13.ametar"��r staling- 'Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION M DESTRUCTION ID {No septic system permitted if public sewer is available within 200 feet.) 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 p Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACWNG LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Property Line SEEPAGE PITS 1 1. Depth Site Number SUMPS L7 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 signature.certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person In such manner as to bocome 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, t shall employ persons subject to workman's compensa- tion laws of California." The applicant all r all repir inspections. Complete drawing on reverse side. r 4 Signed Title: Data: FO DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date— Additional ataAdditional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 .14 SAN JOAQUIN, P O Box 2008, STOCKTON, CA 85201 CK INF/q} AMOUN�7r�OUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. EM-4,24 rlt EY.r�nSr ! r.- e— EN _KJ