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91992 APPLICATION a�. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES _ ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 ' P 0 BOX 2009, STOCKTON, CA 95201 . 'PERMI YEAR E ISSUED .�A I (Complete in ) Application is hereby made to Sas Joaquin County for a permit to construct and, install the wrg4t jirerreefe"tiesc�sbed. This application is made in capllance,vlth San Joaquin County Ordinance No. 549 and 1862 and the Rules V54"uljh'tiong of San f Joaquin County Public Health Services. -J Job Address CUD 46r)' a city/_2ft� Lot Site/A r-age I IF C Address ` 1 L✓+ ��1 M., Phone Owner's Name � ��' Contractor ---Address 8� � License No. �ZZC+g Phone TYPE OF WELL/PUMP NEW WELL ❑ WELL`REPLACEMENT ❑ DESTRUCTION Out of Service We D ' ..PUMP INSTALLATION D: SYSTEM REPAIR 0 _.OTHER Monitoring Well � ver -.a..-- •.+��:+ -"r r -=-:g_-'r.�,::�_��►.r'�.�.�1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD �'� PROP. LINE '' / FOUNDATION - AGRICULTURE WELL OTHER WELL PITS/SUMPS / INTENDED USE TYPE OF WELL PR BLEM AREA CONSTRUCTION SPECIFICATIONS CJ Industrial ❑ Open Bottom YManteca Dia. of Well Ex ion Dia. of Well Casing C1 Domestic/Private (Gravel Pack ❑ Tracy Type of Casing ll' y� Specifications -f I'1 public i"1 Other f n Delta Depth of Grout Seal Type o1 Grovl�r I I Irritation Approx,Depth 1 I Eastern Surface Seal Insialled by Y-ct Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameters Sealing Material i Depth \ Depth ( Filler Material i Depth' TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/AODfTION I I DESTRUCTION I I INo septic system permitted it public sewer is d 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 SEPTIC TANK. ❑ Type/Mf6,1 Capacity No. Compartments PKG. TREATMENT PLT.❑ t Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I DepthSize_ Number M SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, statelaws, an 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, 1 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 C rnia." The applic nt mu t call for all re irad in ¢ec"ons. Complete drawing on reverse side. Signed _ Title: ✓ ///� Date: Zi { FOR DEPARTMENT USE ONLY T Application Accepted by ' Date ~" Area r Pit or Grout Inspection by / Date Final Inspection by Date Z Additional Comments: ! I Applicant - Return all 'copies to: San Joaquin County Public Health Services I Environmental Health Permit/Services r 445 N San Joaquin, P O box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE 1 AMOUNT REMM/IrrEO KS CASH RECEIVED BY / DATE PERMIT"NO. • EM 12r IREt+.,i 3! �O�"D tL�C/� EM t4-�-xb 7T"'"