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APPLICATION ,:FOR PERMIT - I r SAN JOAQUIN COUNTY PUBLIC EEALTH SERVICES. ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 "R PROM DATE ISSUIM (Complete inTriplicate) I,! a ! Application is hereby made to San Joaquin County for a permit tolconetruct and/or install the vork herein described. This application is made in co:aplisnce vith San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulationa'jof San Joaquin County Public Health Services. 16115To Job Address __ �Q1V1 e �� I _ € City araC Lot Size/Acreage 53 Jif. Owner's NamoSer O 13v i_0 r m CV eclj T Address C=�= c -CA 9,sZZ)o Phone 93/-3 X 70 �r-) e Contracto" 1 M r AOI' [)' I Address?v"&7A 3S It S License No.42MPk f Phone C 5-4/7 r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service ►fell'. ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 1) OTHER (8� Monitpring well , ❑ H6,,,d _�r�� DISTANCE TO NEAREST: SEPTIC TANK J� r SEWER LINES 140il C_ DISPOSAL FLD. QAI PROP. LINE P+ Hd eS ] FOUNDATION AGRICULTURE WELL �Ir OTF(ER WELL 1kLn e PITS/SUMPS li INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I 0 Industrial ❑ Open Bottom ❑ Manteca Dis, of Wolf Excavatti�i)opn Dia. of Well Casing �tQ Domestic/Private ❑ Gravel Pack ¢Z Tracy I. Type of'Casing_..r Yet'a Specifications M Public Other ❑ Delta Depth of Grout Seal I p eF Type of Grout 000Qr4!�c_ - - G Irritation iC Approx. Depth' ❑ Eastern h Surisce Seal Installed by Repair Work Done 0 Type of Pump -A&4 H.P. �! State Work Done Well Destruction ❑ Well Diameter Sealing Patcrial i Depth &1.e&4 T1s Depth Filler Material i Depth j11 j TYPE OF SEPTIC WORK: NEW"INSTALLATION 0 REPAIR/ADDITION M.i DESTRUCTION Ci (No septic system permitted it public sewer is:. available within 200 feet.l Installation will serve: Residence_ Commercial_ Othert. Number of living units: Number of bedrooms # Character of soil to a depth of 3 feet: Water table depth m t SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments + PKG. TREATMENT PLT. 0 a t 4 Method of Disposal I Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/site y FILTER BED Cl Distance to nearest: Well Foundation Properly Line x SEEPAGE PITS 11 Depth Sire i•� __. Number SUMPS LI Distance to nearest: Well Foundation Property Line j DISPOSAL PONDS ❑ i I hereby certify that I have prepared this application and that the work will be done in aceoroanee with San.Joaquin county ordinances, slate'taws, and I rules and regulations of the San Joaquin County ti sur W ! Home owner or licensed agent's signature conilies the following: "I certify that in the performance of the work for which this permit is issued!'I shall not 1 employ any parson in such manner as to become subject 10 workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify Chet in the performance of the work for which this permit is issued. I shell employ persona subject to workman's compensa- tion laws of California." ; ,y The applicant)must All for requ r d ins ttiio/nf. Complete diawing on revem'a side. ; Signed Title: Date: S /D IF. FO •r DEPARTMENT USE ONLY Application Accepted by t Date la y�< Area `s Pit or Grout Inspection by e tl-1 ~/Z-Flnal inspection by Date ' Additional Comments: S46 15W,0441volv Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES L l-� `' < ' ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES lrvr`t2.` 445 N SAN JOAQUIN, .P O BOR 2008, 3TUCKTON, CA 95201 / '77 ~I 1 I 3. FEE AMOUNT DkrE AMOUNT REMITTED CK R EIVEO ay DATE PERMi7`NO.`� ]NFO CASH .0 EN 13.71 IREV.lixl)�� 43� /✓/ II /O / '�Cf-O�t� -.M1•Yj„� 1' - ih r '