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r n �vf� APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES p ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN., PHONE (209)468-3420 P .O BOX 2009, STOCKTON, CA 95201 PRIMIT E%PIRES 1 YEAR FROM DATE ISSUED i (Complete in Triplicate) APP11catton In hereby made,to San Joaquin County for a permit to construct and/or install the work-herein described. This application ie made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations.of San Joaquin County Public Health Services. Job Address 00 [T N1 #\J6 City Lot Size/Acreage 1 l Owner's Name —I"UD ! Address x 5 Phone q S-67/S Contractor Address M-0 E 0 5T: ct LD cense NQ.4,29 79(p,Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Out of Service Well C)PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ kOYHER ❑ Monitoring well ❑ DISTANCE TO NEAREST: SEPTIC TANK 5Z; 10 / SEWER LINES PfA — DISPOSAL FLO.75_2 PROP. LINE _LL_0Q r FOUNDATION >. !, „_ AGRICULTURE WELL LL911L OTHER WELL_ 30 r PITS/SUMPS V-10, INTENDED USE. TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS a industrial ❑ Open Bottom O Manteca Dia: of Well Excavation _�•_ Dia. of Well Casino 0 Domestic/Private ❑ Gravel Psck7 ❑ Tracy Type of Casing _ Specifications I"1 Public Cl Other fl Delta Depth of Grout Seal Type of Grout I i Irrigation _Approx. Depth I I Eastern Surface Seal Installed-by Repair Work Done U Type of Pump H.P. State Work Dona Well Destruction X Well Diameter ` Sealing Material i Depth ea+ Depth ) Filler Material A DepthkOt� ,. TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/AODITION I t DESTRUCTION I I {No septic system permitted if public sewer is available within 200 feet.l' Installation will serve: Residence_ Commercial_, Other } Number of living units: Number of bedrooms Character of soil to a depth of 3 feat: 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. & Length of Imes Total length/size FILTER BED b Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS Ll - Distance to nearest: IWell 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, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature oartifies the following: "I certify that In the performance of the work for which this permit is issued,I shell not employ any person In such manner as to become subject to workmen's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work ioi which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Cal' !a." The applican t call for all req uir ins a driiiving on.reverse side. --77 !!�� Signed Tills: G, �4 ! vt 7 Dais: p FOR DEPARTMENT USE ONLY Applicetion Accepted by _? �'C _ Date AM Pit or Grout Inspection by �toaqul DataFinal Inspecctiion by ��'�^�`—� DateAdditlona! Commanu:Applicant — Return all copies to: San County Public Healthc�a�_.Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009; Stkn, CA 95201 ,V! FEE AMOUNT DUE AMOUNT REMITTEb K RECEIVED BY DATE PERMIT'N0: INFO CASH j . EH 13-24IREV.beer EH 14.28 t