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' Ir APPLICATION FOR PERU „ SAN JOAQIIIN COUNTY PUBLIC HEAL H$ERVIEE BNVIRONIIIENTAL HEALTH DIV 445 N SAN JOAQUIN, PHONE (20 )48 1"42o — P O BOX 2009, STOCKTON, C1 9:t2A]�i PERIL MIRES 1 XM FROM D (Complete in Triplicat ' Application is hereby made,to San Joaquin County for a permit to construct and/or Install the work herein described. This application 1s made In compliance with Sea Joaquin County Ordinance No. 549 and 1B and the Rules and Regulations of San Joaquin County public Health Serv1 s. Job Address J k( 4Q �0 �-t GCS City Z` t St. /Acreage �J n Z.� Owner's Nam* ��H J/u�fj 0 Yc a Address!1z;'2. �,''' «- ;��j��GPhohojne tContlactoreiJG.d (L0 --'-A(.G Addres� < Z GY �L� License N4��=Phone- l TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Nell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well ❑ ' - DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLP. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' ❑ Industrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation -_ 04. of Wall Casing rt�LDonpenieJPrivete ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications ('I Public , Cl Other 11 Delta Depth of Grout Seal Type of Grout ' I I Irrigation —.Approx. Depth�n "W�,,Eastem Surface Seal Installed by Repair Work Oona Type of Pump — H.P. .3 State Work Dom WON Desttuciien ❑ Well Diameter ". Sealing Material L Depth ". :r Filler'l6tiii ial i Depth ' Depth i TYPE OF SEPTIC WORK: NEW INSTALLATION I I -REPAIR/ADDITION I I DESTRUCTION I ar Ileo septic system pmirlad it public sswr'ue `�— available within 200 lest.l Installation Wil serve: Residence_ Commercial_ Other ' Number of living units:_ Number-of bedroom - . - 1s� Character of son to a depth of 3 feet: Water table depth l!" SEPTIC TANK - ❑ TV"/MfgCapacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to naaiest: Well Foundation Property Lim .. LEACHING LINE ❑ No. 6 Length.ol linea Total length/size tFILTER BED ❑ Distance to nearest: Well Foundation Property Lina SEEPAGE PITS II Depth -Size Number SUMPS Cl Distance to nesf*N: ' WON 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 lawn, and rules and regulations of the San Joaquin County Horne 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 net ' employ any parson in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature conifies the following:"I artily that in the performance of the work for which this permit is issued,I shall employ Persona subject to workman's companu- Pion laws of California" The Opole u l call or ale required inspections. Complete drawing on rev side. ' Signal Title:�1 Date: F FOR DEPARTMENT USE ONLY ff Application Accepted by Date 1. Area Pit or Grout Inspection by Date Final Inspection by Date io, q- 3P Additional Contrivance: ' r Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Reaitb Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE 14.26 �� NPO EN 1470 AMrOUNT PUE AMOUrN�T REMITTED CASH CK I RECEIVED BY v�]D/ATE PERMIT NO. 1 EN .rrxap c 5 �� //��'� e lw8 F