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APPLICATION FOR PERMIT �..a SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 T VYDTRSS 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Servicees. d �l4,�Zj ti'oRlH / 6QSNf'A-l- Ay�. City j oGLciu/V Lotrise/Acreage Job Address F—Aac,r✓ 00Hf'a't''/ 11IfI Address 23--ocZ4Yr0A1 fiP. n. ro'V20A 6/1 Phone -to 2if68,1'-2,C OwMr's Nama iCcontractor y/LNr}UC= ,UF_GL JAil :Aadress#09 61WP41 0V. CCNWRJJLicense No. �l"s�`2 Phone�zO �' '!l•i TYPE OF WELL/PUMP. NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER Id 6v Fr Fr. DISPOSAL FLO. ' PROP. LINE EF'T DISTANCE TO NEAREST: SEPTIC TANK /OJ FT SEWER LINES r/c 1G Ff PITS/SUMPS FOUNDATION AGRICULTURE WELL IL— OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 21. 1. V. ❑ Industrial ❑ Open Bottom ❑ Manteca Cie. of Well Excavation Iff. Dia. of Well Casing Type of Casing e— Specifications 5cy 40 U Domestic/Private ❑ Gravel Pack ❑ Tracy g ./ Type of Grout�-c'hE All M Public - QC Other Delta Depth of Grout Seal ❑ I igation �J Approx. Depth ❑ Eastern Surface Saul Installed by.�' 4111 uC u ELc, r�2rW v' X �-� r A+ , y H p State Work Done _ Repair wart &;; L3 Type of Pump haying Material i Depth Well Destruction ❑ Well Diameter r Depth Filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION C1 DESTRUCTION CI (No septic system permitted if public sewer is available within 200 feet.l Installstion will serve: Residence— Commercial_ Other r\. Number of living units: _ Number of bedrooms V Character of wil to a depth of 3 feet: Water table depth Z SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. g Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS It Depth Sirs Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 canities the following: "I certify that in the performance of the work for whits this Dermic 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 sub-contracting signature conifles the following: "I comity 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 mustal F required inspections. Complete drawing on reverse side. Q n Deter: 7�A/ Signed Title: -14 FOR DEPARTMENT USE ONLY I �V 'z �j � C�v Application Accepted by 11!/��pp4Data 31.1 e Area `9 1 Pit or Grout Inspection by LY 1�^'^"'i Date 0 7 �+S Final Inspection by N klA-#14 Date/Z 7 r Additional Comments: a'N- 5 SW 1 Applicant - Return all copies to: SAN JOAQUIN CO TY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON. CA 93201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. ` (,,nO INFO 7p[} H . IM 13-24 IaEV.11.sl X�i °•`= �JS JHA-21 :x-s