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r APPLICATION FOR PERM I T _w _ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ; ENVIRONMENTAL HEALTH[ DIVISION P O BOX 2009, STOCKTON, CA 95201 -.-_ (209) 4s8-- jq2-© - 1991 ,nUIT WIRES „,,,YEAR FROM DAJE ISSUED ENVIRONMENTAL (Complete in T- HEALfiH) licate) PERMIES Application is hereby made,to San Joaquin County for s permit to �tqDftJVA.tall the workherein described. This application is made its ccupliance with San Joaquin County Ordinance o. he Rules and Regulations of ban Joaquin County Public Health Services. a Job Address X030 ec'-Zr�� L• � City�A Lot Site/Acreage .dP.�OX. .4 lv.4Ce5 -F 6fr2557- _!C-7"" 69: s61/r.6 3y4--o Owner's Name .P�� h'P� S c.�S / Address k �Q��- 1'-'Wk-P-5- /0421y Phone 0�'oSvs 1Y� -e4Ea I e!s 7a Contractor ,z;EAG<'��1�b_�✓�-�i7-,�- , .C94ddress /Y� _ _ -- _ License No. Phone /V TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT C-# DESTRUCTION 0 Out of Service Nell 0 PUMP INSTALLATI SYSTEM REPAIR ❑ OTHER 9' Monitoring well rl M ��'r �esr'w , p rER.a�r�a So/L TESTj3v iNFi DISTANCE TO NEAREST: SEPTIC TANK._ SEWER LINES H�A DISPOSAL FLD.i, PROP. LINE ��dt'E 2 FOUNDATION F ✓.tom 2 AGRICULTURE WELL > r OTHER WELL L�'°a!' PITS/SUMPS% � �� LIPo,W 7 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f-1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation X1.4____ Dia. of Well Casing ['Domestic/Private Cl Gravel Pack n Tracy Type of Casing, e-VISpecifications M Public (-)-Other ScWW6 ❑ Delta Depth of Grout Seal /v.FT ,m4¢r _ _ Type of Grout E G Irrigation A! Approx. Depth ❑ Eastern Surface Seal Installed by Qft'/�Y✓�/��✓MFX1 �_ /.r/L. Repair Work Done 0 Type of Pump111 H.P. _ eZA ___-____ State Work Dona 1cT�ST Bmarrr/r O Well Destruction ❑ Well Diameter e1A Sealing Material i Depth qJ Depth _-/p e!2 /$ Filler Material i Depth efz.d _ Cj TYPE OF SEPTIC WORK: NEW INSTALLATION L1 REPAIR/ADDITION 0 DESTRUCTION CI (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 n SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line a LEACHING LINE Cl No. b Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LIDistance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I'hays 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 become 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, I shall employ persons subject to workman's compensa- tion laws of California." The applican at 11 f r all it inspections. Complete drawing on reverse side Signed Title: O Date: 9 t V NM NT�YI-� A�er-o EPART W T USE ONLY Application Accepted by Date 6 Ar 3 Pit or Grout Inspection by Date Final Inspection by Dat Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 X SAN JOAQUIN, P O SOX 2009, STUCKTON, CA 95201 FEE INFO �AMOUNT DUE AMpI1NT REMITTED CASH RECEIVED By DATE a PERMIT NO.