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/0 3o APPLICATION 3. v Nos 72,7774C<2.o E" q f•r ps BiC c n� �- SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES p`/ ENVIRONMENTAL HEALTH DIVISIONfJ 445 N SAN JOAQUIN, PHONE(209)469-3420 P 0 BOX 388, STOCKTON,CA 95201-0388 PERMIT WMIRES 1 YEAR FROM DATE ISSUED ^" (Complete in Triplicate) -_�O_��/�.-tr=_�:•i:N. ,1ht��E(1�-sem.._. ..,-'� dC7� — 2.30-- E�J.3 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 Development Tit a Section 9-1110.3 and Section Z5.3 and the Rules and Regulations of San Joaquin County Public Health Services. Job Addres l' 1 Gty Lot Size/Acreage O er't Name �- •U�n�� Address' - ------ t- - t_ contractor J, TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT rl DESTRUCTION VOut of Service Well , ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR D 't - ' OTHER C3 Monitoring Well C] DISTANCE TO NEAREST: SEPTIC TANK_ SEWER LINES t DISPOSAL FLO. PROP. LINE t FOUNDATION. AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom O Manteca r Dia of Well Excavation Dia. of Well Casing i 1 Domestic/Private I D Gravel Pack 1 0 Tracy Typo of Casing_ I Specifications I'1 Public fl Other ` a.n Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by I Z Repair Work Done U Type of Pump H.P. State Work Done Well Deft — rr Sealing Material &'Depth Destruction Diameter�r r t Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/AODITION I I DESTRUCTION I I INo septic system permitted it public war is l 2 available within 100 feet.l " Installation will serve: Residence _Commercial_ -Other Number of living units: Number of bedrooms y r 1T - Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg f Capacity No. Compartment PKG. TREATMENT PLT. U Method of Disposal *" Distance to nearest: Well Foundation Property Line PAYep;IdL. !4Y LEACHING LINE 0 No. & Length of lines I Total length/size c s` yy��` E 0 i FILTER BED - ❑-'Distance to nearest: Well Founoauon Property Line RI(I1/ C ,()01 SEEPAGE PITS 11 Depth Size Number r CGUN`tY SUMPS LI -Distance to nearest: Well Foundation Property Lina of IRWEALTH SERVICItS ' .0 ENVIRON I T FA. ' e,1 N ' DISPOSAL PONDS E)1 he by certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stere 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 periormance of the work for which this permit is issued, 1 shall not signature employ any person in such manner as to become subject to workman's compensation laws of California."£ontrectonsrsubjectring it worktman's9ompensa certifies the following: "I certify that in the performance of the work for which this permit is issued. I shell employ pe tion laws of California." The applican must II It required inspections. Complete drawing on reverse side. - r Signed X Title: 6(km � Date: �--'�`� "`� FOR DEPARTMENT USE ONLY -� __ Date Area Application Accepted by u Pit or Grout Inspection by V & cl ` Date Final Inspection by - Date / 24Y Additional Comments: San Joaquin County Public Health Services Applicant - Return all copies to: Environmental Health oxServices v 445 N.San Joaquin,P.O.0,Box 388,Stockton,CA 95201-0388 ,lI,f�i O a FEE AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY DATE �I PtEtRM1T NO. ( ) 3 1Q O INFO 111 I 7�� all � �.4( �/ � —to