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APPLICATION lis 5ai,oJ SAN JOAQUIN COUNTY PUBLIC HE T V '//`0 ppll9 ,S �3a _f_ ENVIRONMENTAL HEALTH D VI / r 445 N SAN JOAQUIN, PHONE (2 WIP3420 f/ 170 P O BOX 2009, STOCKTON, PERMIT EXPIRES 1 YEAR FROM Complete in Triplit��t�+# LI Application Is hereby made to San Joaquin County for a permit to construct 1I''YY YY e v is application is made in Compliance vith San Joaquin County Ordinance No. 5t9 and 1862 and the Ru es an n Joaquin County Public Health Services. Job Address 865 F Roth R rl CnyF r r n r h Cn m¢,ot S1 ze/Acres.ge Owner"s Nam.Pa C i f I C P r e C a S t „ Address .3508 D P jetzt Rd H a v ig a r rl Phone8677 Contractor C1 Address 2n"___ (+jiarpr- License No, Phone)(19 462-7 76 TYPE OF WELL/PUMP: NEW WELLK®xx WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Veil ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well U DISTANCE TO NEAREST: SEPTIC TANK.t.1 SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ 1 6 Ir Dia. of Well Casing rt r I Domestic/Private XCJ Gravel Pack r-1 Tracy Type oasin TTf C X g_—.q t f".I 5pecificatioris , I'] Public 1-1 Other Cl Oeea Depth of Grout Seal Type of Grouter tt 11 IrripatOn _ Approx. Depth Ii Eastern Surface Soul Installed by Repair Work Done U Type of Pump 5 tt h H P. 5 State Work Done _ rR 9 t=a I} Well Derstruction ❑ Well Diameter Sealing Material i Depth p(� Depth Filler Material E Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADOiTION I I 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 unite: Number of bedrooms Character of soli to a depth of 3 feet: _ Water table depth SEPTIC TANK ❑ Type/Mfg Capacity_ No. Compartments PKG. TREATMENT PLT. C1 Method of Dispoul Distance to nearest: Well . Foundation _ Property Line LEACHING LINE L1 No. & Length of lines Total length/site FILTER BED C.l Distance to nearest: Well Foundation _ Property Line SEEPAGE PITS 11 Depth __Size _ Number SUMPS LI Distance to nearest: Well, Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this -ipplicatlon and that the work will be done in accordance with San Joaquin county ordinances, stale laws, and rules and regulations of the San Joaquin County Norse owner or licensed agent's signarure certifies the following: "I certify that in the performance of the work for which this permit is issued, i shall not —play 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 throt in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compenu- lion Iowa of California." The applicant au t d; r qtrplate drawing on reverse side. Signed Title:V P Clark Well , Ina Date: -18 ()r t 9� FOR DEPARTMENT USE ONLY Application Accepted by Ar Pit or Grout limpection by Date 1 t7Final Inspe /1 Date � Addl6oniel ommenn: �'Tjj C �� wv Appl c� / 10 .t(. nt - Return all copies to: San Joaquin County Public Health Services, f f Lr t Environmental Health Permit/Services 445 N San Joaquin, P 0 Dox 2009, Stkn, CA 95201 FEE . Vl AMOUNT DUE AMOULN�T/'REMITTED RECEIVED BtY Dai7 9E PEMNi�T �INFO AM 5Ht7-2�IHEY.tiAs� // ` 4r EN 14-20 A �