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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468--3,W 3 'L/"-70 �4$" . Y R O�C j I,, (Complete in Triplicate) 4/� J d Application is hereby atade,to San Joaquin County for a permit to construct and/or installk herei cribed. This application is made in Compliance with San Joaquin County Ordinance No. 549 and 1862 and t d Reguu tions of Ban Joaquin County Public Health Services. / �T� qf Job Address Tii-o W G/'4lrtf d City r.4ze -- Lot Size/Acre Owner's Name o t? Address ---- Phone's f Contractor C �r �11L1 Address d t33o License No.C- Sprdz7v PhoneZ- W01-08z-1 TYPE OF WELL/PUMP: NEW WELL ® WELL REPLACEMENT n- DESTRUCTION ❑rOu't of Service Nell D PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE �n-sod• FOUNDATION 24 AGRICULTURE WELL OTHER WELL PITS/SUMPS .� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �t Cl industrial O Open Bottom ❑ Manteca Dis. of Well Excavation O Dia. of Well Casing FN Domestic/Private DIG&avol Pack IN Tracy Type of Casing PUC - Specifications ❑ Public Ill Other ❑ Delta Depth of Grout Seal Maf yet knawK.*- Type of Grout O Ml Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done U Type of Pump r-9A)4- H.P. State Work Done Well Destruction ❑ Well Diameter t u a Sealing Material i Depth 3 �,• o.+� � Jl:41 ro pJ4-# CJL pepth'�-- Filler Material i th TYPE OF SEPTIC WORK: NEW INSTALLATION fl REPAIR/ADDITION 0 DESTRUCTION G (No septi system pe fitted 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/sire FILTER BED is Distance to nearest: Welt Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS Ll Distance to nearest: Well 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 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 subcontracting 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 applicant mu 1 call for all required ins ti s. 29m*to drawing on reverse side. 1 Signed Title: J�1eilh �i '7r d __ Date: +r OF F EPARXftEJWT USE ONLY Application Accepted by Date � Plf��pr Grout•Inspection by Date "g Final Inspect€an b Data 2 �� d'. t /�F�Jtlona! CoASmantt: ' AA t - Redy= all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN. P O BOX 2009, STOCKTON, CA 95201 ' T_-OFEFEO AMOUNT DUE AMOUNT REMITTED CASA RECEIVED BY DATE PERMITNO. EN A'24 26tREV. y �1 �8 EM:616 [�