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I APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � ENVIRONMENTAL HEALTH DIVISION I P O BOX 2009 , STOCKTON, CA 95201. (209) 468--3447 PERXIT EUIRES 1 YEARYROM DA7LE ISSULD ; (Complete iu Triplicate) ;? li i Application is hereby made,to Sem Joaquln County for a permit to construct and/or install the work herein described. This application It made in compliance with San Joaquin County Ordinance;No. 549 and 1862 and the Rules and Regulations of San 1 Joaquin County Public Health Services, r I Job Address _=� testi r City rf Lot Size/Ac�reage Owner's Name �l Address 2 4�R 12 14 41;r_ �Vu�� Phone Contractor // - � [rn C Address .�`� .+=�+ 7C "C EL ��x��-' License No,,'S /,�/:Z_Phone. TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT C_l DESTRUCTION ❑ out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM Rs EPAIR 0 OTHER Cp 15 Monitoring well l ir,... �vzr+s6r5 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom 0 Manteca Die, of Well Excavation . " Die. of Well Casing U Domestic/Private L1 Gravel Pack 0 Tracy Type of Casing--- Specifications 0 Public X•Other ❑ Delta Depth of Grout Seal Type of Grout &r' M Irrigation —Approx. Depth Cl Eastern Surface Seal Installed by 1; Repair Work pone U Type of Pump H.P. State Work Done 51aiL�c.�flae Sealing Material i Depth rl Well Destruction ❑ Wall Diameter Depth Filler Material &;Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Cl DESTRUCTION C1 (No sepric system permitted if public sewer is available within 200 feet,) r Installation will serve: Residence Commercial— Other {. Number of living units: Number of bedrooms � 1 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. 0 Type/Mfg Capacity No. Comport ri ants PKG. TREATMENT PLT. ❑ Method of Diipoaal Distance to nearest: Well Foundation Property Line .I LEACHING LINE Q No. & Length of lines Total length/size FILTER 8ED n Distance to nearest: Welt Foundation Property Line I� If SEEPAGE PITS 11 Depth Sire Number aj SUMPS Li Distance to nearest: Welt Founded'on Property Line li DISPOSAL PONDS ❑ it 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 „ li Home owner or licensed agent's signature certifies the following; "I certify that in the performance of the work for whlcfl this permit is issued, I shall not employ any person in such manner as to become subject to workmen's compensation laws of California." Contractor`s hiring or subcontracting signature certifies his fot wing; "I Certify hat in the performance of the work for whichInAl mit is issued, I shall employ persona subject to workman's compensa- tion laws of alifornla." The applica t u t call for a requira specti amplaw drawing on ree. JI Signed Title: Date: -- —� � _ DEPARTMENT U5 ONLY I'. Application Accepted by Dater1lelfes Pit or Grout Inspection byDate Final,Inspection by Dats - Additional Comments: I� Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 95201 I, FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED 9Y DATE I� PERM17 NO. c INFO . EH 17.24 MEV.neer diJ �� \p •i..� { ! I F��' EN;..m VV J