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APPLICATION FOR PERU SAN JOAQUIN COUNTY PUBLIC HEALT ENVIRONMENTAL HEALTH DIVI 445 N SAN JOAQUIN, PHONE (209- t #�18O.saa a► P 0 BOX 2009, STOC%TON, CA 5ft R PERMIT EXPIRES 1 YEAR FROM DAT ISSUED �at-( (l _ (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 San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Slerv1 ea. Job Address w/J k � �z 1[/�Lf. City I�el/�� Lot Size/Acreage it-1k X r Owner's Nam //� f / ��-' Address, �l yr�'_"�'L'/�� Phone ' J Contract r r r ta.1 a/ Addres �.rJ� /(Lz / y�� License No. 7 Phone- r"� 5/fir TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ .s PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Ll Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ Specifications I.1 Public 1-1 Other Il Delta Depth of Grout Seal Type of Grout �\ W I 1 Irrigation _Apprax.-Depth I I Eastern Surface Saul Instilled by lam. Repair Work Done. U Type of Pump H.P. State Work Done_ Well Destruction ❑ Wall Diameter Sealing Material i Depth Depth Tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sower is available within 200 feet.) Installation will"No: Residence Commercial_ Other / Number of living units: Number of 'ms Character of sell to a depth of 3 feet: - / u2 '-r_[Lf.-s I Water table depth / SEPTIC TANK. Type/Mfg L�. i ' Capacity &-c-e No. Compartments —. PKG. TREATMENT PLT.❑ / / Method of.�DIS19s�al Distance to nearest: Well Foundation Property Line _ LEACHING LINE No. d Length of lines ` d Tgtal length/size Z' FILTER HED /❑ Distance to nearest: Well��`14 Foundation �/1" Property Line SEEPAGE PITS Depth Sia_ �' Number SUMPS LI Distance to nearest: well zF Foundation �/� r f 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, end 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 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant ust call for sll�ulr d inspections. Complete drawing on reverse sid._-'� rylY i Signed tiE C Title: Data I ., FOR DEPARTMENT USE ONLY / Application Accepted by � Date c -t AreaZz r 6/or Grout Inspection by DateL_/Q—q ?_ Final Inspectionby��> -br,/�// -cti+f DatacJ— �.p Additional Comments Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services ee, 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 �f / r�` FEE AMOUNT AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMI7'NO. . ENtam id4 IREV.wear �f.00 n (y _ EN ta. ACJ i '7