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APPLICATION. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 q p O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .. (Complete in Triplicate) Vork in described. Application is hereby compliance withuin SanCounty J aquinor a county ordinanceerinit nNoru54 andct or install 1862 and theeAules andeRegulations of Sans application is made in comp Joaquin County Public Health Services. City Lot 81ze/Acreage Job Address rsa Phon Address Owner'a Name �7 ense N � �Phone a, Contra Addre TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION L1 Out of Service Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ! FOUNDATION AGRICULTURE WELL OTHER'1VELL PITSISUMPS INTENDED USE TYPE OF WELL' PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Weil-Casing n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Type of Casing. Specifications li (:1 Domestic/Private ❑ Gravel Pack❑ Tracy Depth of Grout Seal Type of Grout Il Public Cl Other #t n Delta I i Irrigation _Approx. Depth I I Eastern Surface Sea! Installed by of Pump H-P. State Work Done — Repair Work Done L] Type Material 8 Depth Sealing Well Destruction ❑ Well Diamet'r Filler Material i Depth pt- Depth iTs TYPE OF SEPTIC WORK: NEW INSTALLATION 1 .1' REPAIR/ADDITION DESTRUCTION l I asepticNo vailablewthin 200 feet.) if public sewer is Installation will serve: Residence>, Commercial _^ Other Number of living unite: �� 'Number of bedrooms Water table depth Character of soil to a depth of 3 feet: No, Compartments SEPTIC TANK ❑ .Type/Mfg Capacity Method of Disposal PKG.,TREATMENT PLT.❑ 1 T Distance to nearest: Well Foundation Property line f No. & Length of lines Totyl lengthlsize LEACHING LINE r propeity line . FILTER BED ❑ Distance to nearest. Well QO - 7 Foundation SEEPAGE PITS X. Depth !i Size /�—�y dumber e SUMPS I_I Distance to nearest: Well l s1_s.� Foundation Property Line DISPOSAL PONDS ❑ 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 1 . Home owner or licensed agent's signature certifies the following; "I certify that in the performance of the work for which this permit 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 certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compansa- tion laws of California. The applicant m at alt for all requir s ti comp! drawing on reverse side. Date: Signed -" Title: . OR DEPARTMENT USE ONLY Date Area Application Accepted by 611,r Grout Inspection by pate > ;_ Final Inspection by Da e Additional Comments: i oaquin Cunty Pblic Health ser Applicant - Return all copies to: gnvi�onmentaloHealthuPermit/Servicesvices 445 N San Joaquin, P O Box 2009, Stkn, GA 95201 FEE CK RECEIVED BY DATE PERMIT'NO. AMOUNT DUE AMOUNT REMITTED CASH INFO EE z3 0l E�F1 r EM 13-24{r1EV.l/K Si �-ATZ) EH 14.26