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APPLICATION FOR PEPWIT - SAN JOAQUIN COUNTY PUBLIC HEALTHfrAC V ENVIRONMENTAL HEALTH DIVIS � P 0 BOX 2009, STOCKTON, CA 91 (209) 468-13420 2-BUTT EXPIRES I A (Complete in Triplicate) Application is hereby made to Sas Joaquin County for a permit to construct and/or install the work herein escribed. Thi. application is made in coarpliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulat�ona of San Joaquin County Public Health Services. Un/ CtTt� 0,ZC'i>62Ty- Aon, /✓,'r A—' Job Address BOO E, MAjiKi S;. City CJTOC1CTOAJ Lot Size/Acreage Owner's NameRJyeP_rto P-4,00YF Address P.o-t3OX 923 S-rma and Phone 948- _3048 j2A"c 64- Contractor Address Ea. Y, 2231 CA2m11A 9574/ License No.4-726/7 Phone f- -9SSg TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT O DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR O L1�cc�-OTHER � SMonitoring Well �� C3 '' ��, . DISTANCE TO NEAREST: SEPTIC TANK _! L? SEWER LINES S� r DISPOSAL FLD. N14 PROP-LINE 'S' FOUNDATION �JAGRICULTURE WELL/_1/Z±_ OTHER WELL,± PITS/SUMPS YZd INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing A1111-f- 0( ll/-t Q!.Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing NoNc Specifications ID Public KOther O Delta Depth of Grout Seal $t/J2Ff}Gf Type of Grout L'5-44cA/f CI Irnpation 14QL�Approx. Depth O Eastern Surface Said Installed by CoNrQ,aGToiz- Repair Work Done U Type of Pump H.P. State Work Done _ Wall Destruction O •• Well Diameter Sealing Material t Depth Depth Filler Material ii Depth TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION 0 DESTRUCTION U (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial_ Other PAYMENT w YMENT r Number of living units: Number of bedrooms C►�+ Character of soil to a depth of 3 feet: Wi1011l`de'Ri ` SEPTIC TANK O Type/Mfg Capacity_ 'Ptt•"ltm4- PKG. TREATMENT PLT. 0 SA G° �tof Ilhl DispornIR' )l'sal � l Distance to nearest: Well foundation P� ��;ir�o��+ _ CSS LEACHING LINE 0 No. b Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation _ Property Line t` SEEPAGE PITS 11 Depth Size _ Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 1 hereby sonify that I have prepared this application and that the work will be done in accotoance with San Joaquin county ordinances, state laws, and. rules and regulations of the San Joaquin County `tt- 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 tt 1 cenifies 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-l° tion laws of California." The appliciinit�Jmu call f r all required inspections, Complete drawing on reverse side. Signed Kv" Title: 6ous.�r o A.1_ Date: __f4171674-_ FOR DEPARTMENT USE ONLY Application Accepted by Date Pit or Grout Inspection by Date Final Inspection by J Date L s s Additional Comments: _ Applicant - Return all copies to: SAN J UIN COUNTY PUBLIC HEALTH SERV CES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES Do 445 N SAN JOAQUIN. P 0 BOX 2009, STOCKTON, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CXS Ft� RECEIVED By DATE JEAMI� JJ O. EH 14•24 IRfV. EH -.4-26