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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH ENVIRONMENTAL HEALTH DIVIS 445 N SAN JOAQUIN 1`1 -16N -E'(209) 46 P O BOX 388, STOCKTON. CA 95201 Complete in Trip lica e;)_ IV # z, Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is ma a in com;nance Joaquin County Development Title Section 9-11103 and ection 9-1115.3 and the Rules and Regulations of San Joaquin Cotraty Public Health Services. Job Address50�0 r City g41+ot Size/Acreage It Phone .- l �3 4 Owner's Name ) �ayL� Address - 11 V Contractor, !,'IS lir L�[1KC' Address #�10&^ r i_icense`No.,� TYPE OF WELL/PUMP: NEW WELLoCe— WELL REPLACEMENT M DESTRUCTION ❑ Out or Service Well PUMP INSTALLATION G SYSTEM REPAIR. 0 " OTHER ❑ Monitoring Well i DISTANCE TO NEAREST:,��_ SEPTIC TANK,SEWER LINES �QJa DISPOSAL FLD./ _ _PROP. LINE?-- FOUNDATION l — AGRICULTURE WELL OTHER WELL At/ .FITS/SUMPS r INTENDED USE Cl Industrial tpCiDamesticlPrivate I'I Public I I Irrigation Repair Work Done Well Destruction OF TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Open Bottom ❑ Manteca - Dia. of Well Excavation Dia. of Well Casing -gavel Pack ❑ Tracy Type of Casing_ G Specifications I'1 Other � e� 171 Delta Depth of Grout Seat200' Type of Grout - Surface &pth I I Eastern Sur#ace Seal installed by U Type of Pump H. P. State Work Done O ❑ Well Diameter Sealing Material A Depth Depth filler Material i Depth 3RK: NEW INSTALLATION l I REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is ' available within 200 feet.) Installation will serve: Residence — Commercial _ Other PA"e ■ mCE NT Number of living units: Number of bedrooms T Character of soil to a depth of 3 feet: _ RECEIVE water table depth _ SEPTIC TANK i ❑ Type/Mfg Capacit"._ Vgiro. Compartments PKG. TREATMENT PLT. Cl N JOAQUIN OU of Disposal Distance to nearest: Well Founda�A(f." r.f f fee, zu rm..,_lnm LEACHING LINE FILTER BED Cl No. 6 Length of lines Total length/size n Distance to nearest: Wall Founoation Property Lina ?- M h� SEEPAGE PITS I I Depth Size Number l� SUMPS L1 Distance to nearest: Well Foundation Property Lina 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 ignature certifies the following: 111 certify that in the performance of the worts for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's. hiring or subcontracting signature certifies the following: -I certify that in the performance of the work for which this permit is issued, 1 shall employ pentons subject to workman's compensa- tion laws of California." _ The applicant ust call for all required inspections. Complete drawing on reverse side Signed Title: t? Date. FOR DEPARTMENT USE ONLY Application Accepted by Dates !D Area 1 /a Pit 009 spection by Date Final Inspection by 0& -�/�/.�i.�/75i 4 .� 41 Additional Comments: Applicant -�Retu tI` 11 f C . Fla 13-24 rit—tilt Eh 14.2s. 1 copies to: San Joaquin County Public Health Services y a' Environmental Health Permit/Services 445 N. San Joaquid, P.O. Box 388, Stockton, CA 95201-0388 i .r A ti FEE 'AMOUNT DUE AMOUNT pEMITTED t: H RECEIVED 8Y .DATE. 1INF EEO