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APPLICATION SAN JOAQUI14 COUNTY PUBLIC FIRATTI 3 ENVIRONMENTAL HEALTH DIVI QATni 445 N SAN JOAQUIN, PHONE (209 =3 P O BOX 2009, STOCKTON, CA PERMIT EXPIRES I YEAR FROM DAT_, (Complete in Triplicat ) Application is hereby made to San Joaquin County for a permlt to construct and/or install the work herein described. This application is wade in coopllance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Hes.1th 8e� ices. Job Address I�GL It-s ` �1 1 C i M� lsY Lot Slze/Acrer-g eJ" Owner's Name aptI'� Addres�J+�+ �/sem ��W w` Phone Z ContracIA-_n 645" Lmoi AddfesBOM • 14ftilto1a Wq License N52b&-1 r Phoney TYPE OF WELL/PUMP NEW WELL^ WELL REPLACEMENT n DESTRUCTION Cl Out of Service Nell O PUMP INSTALLATIO SYSTEM WAIR 0 OTHER O Monitoring Well [3 DISTANCE TO NEAREST: SEPTIC TANK _ i SEWER LINES AX DISPOSAL (LD. PROP. LINE FOUNDATION — AGRICULTURE WE L OTHER WELLPITS/SUMPS INTENDED USE TY OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial Open Bottom 0 Manteca Dia. of Well Excavation. Dia. of Well Casing f!ttomeslic/Private ❑ Gravel Pack 0 Tracy Type of Casing � Specifications I'1 Public n Other r1 Delta Depth of Grout See; loot Type of Grout I i Irrigation _Approx. Depth i I Eastern Surface Seal installed bv, �sl�tT- -=--rm - Repair Work Done L3 Type of Pump SA6 M.P. 2- ___ — StatA Work Dona _ well Destruction O Well Diameter Sealing Material s Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR/ADOiTION 1 1 DESTRUCTION I ! INo septic system permitted if public sewer is available within 200 leat.f Installation will serve: Residence_ Commercial_ Other Number of living urate: Number of bedrooms ` Character of soil to a depth of 3 fest: Water table depth SEPTIC TANK 0 Type/ g Capacity No. cRUMENT PKG. TREAT ME T T. ❑ ° Q Mol"REOMED Aka %Dee to nee Well Foundation Property Lin+y , JUf� L I 1994W \ LEACHING L O o V th of lines _ Total length/si 1 A UIN COUNTY FILTER HED rl Drstancs to nearest: Weil _ Foundation PHEALTH SERVICES r L �j��TH DIVIStON l SEEPAGE PITS' 11 Depth a Number SKIMPS LI Distance to nearest: Well Foundation Property Lime DISPOSAL PONDS ❑ r' I hereby certify that I have prepared this application and that the work will be done in accordance with San,loaquln county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature csnif'bs the following: "I certify the? in the performance of the work for which this permit Is issued, 1 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 compensa- tion laws of California." The applicaamust all for al red inspectlono. C mplete drawing on reverse side. �7 Signed Title: C1 s� Date: FOR DEPARTMENT USE ONLY Application Accsple�dr by t Date J Area Pit Grout jspeetionby�3: »erolM Date C � 9 Final Inspection by Data /LTi Additional Comments: /amu ss C-r- da PYL Appli•s t - Return all�cs ito:2 San oa sin Co my Pub11L�-]ECalth Services l 2 Environmental Health Permit/Services 1 7 }}�✓ 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 f �� 4, AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMI7 NO, EM 13-24 OIEV,a i■si /��J�n}b 1