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r APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES _ I `� ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468—a4ff v t4AY 1991 Y3AR (Complete in Triplicate) ENVIRONMENTAL HEALTH Application is hereby made to Sari Joaquin County for a permit to construct and/or install the vork hereindescribed. This Application is nrade"in coatpliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joequia County Public Health services. I Job Address �. 1y,a=- _ City-�4�.� Lot Size/Acreage ,�f1,�, s 9 W,—g97- S9 ra s9: JIQW71.6 3rys0 zI z) Owner's Name �/ �P/Sc S [.fs / Address AYE y�w ,� /oaig Phone -osaS �o,Pir cljS Tp Contractor A. p,�/cl..�'.o �Cs4ddress /r/ H License No. �Phone TYPE Of WELL/PUMP: NEW WELL..tet WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Wall Cl PUMP INSTALLAT!P� ❑ SYSTEM REPAIR ❑ OTHER 27. Monitorirs Well DISTANCE TO NEAREST:SEPTIC TANK /VFX SEWER LINES 4� DISPOSAL FLD, .v PROP, LINE 2 f FOUNDATION T 2, AGRICULTURE WELL ]Io__-oo^ OTHER WELL 71asvgaro `s4FAA s "" _ P17S/SUMPS/.y„�.sr4v INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i.} Industrial ❑ Open Bottom 15 Manteca Dia. of Well Excavation .t V00mesticlPrivate Dia. of Well Casing ❑ Grave! Pack E3 Tracy Type of Casing A M Public R'Cither AUW4V6 Specifications. rr !� Delta Depth of Grout Seal -h6T�rdX._ Type of Grout��E Q Ifrivation �Approx. Depth El Eastern Surface Seal Installed by Repair Work Dona U Type of Pump . H,P, ----yld State Work Done tic TEST Bo�iy/ O Well Destruction ❑ Well Diameter sealing Material & Depth I Depth o�9' �! Filler Material 6 Depth /fz/4 I TYPE OF SEPTIC WORK; NEW"INSTALLATION Ll REPAIR/ADOITION CC DESTRUCTION CI'(No septic system permitted if public sewer is Installation will serve: Residence 4Commercial_ available within Zt�O feet) Other _ Number of living units: Number of bedrooms Character of$011 to a depth of 3 feet: SEPTIC TANK- Water table depth ❑ Tt1 yge/Mig t l PKG. TREATMENT PLT.❑ Capacity� No. Compartments Method of Disposal Distance to nearest: Well Foundationh Property Line i LEACHING LINE C1 No. $ Length of lines t� S FILTER SED Total length/also n Di stance to nearest; Well _ Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Cl Distance to nearest: Wall Foundation DISPOSAL PONDS ❑ Property Line I hereby conity 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 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 tion laws of California." p R Y persona subject so workman's compensa• I I A The applican st II for all uir inspections. Complete drawing on reverse side 5 Signed Title: Date: 9 ►�+VV AlMr= .- IrIIC,FO EPART T USE ONLY Application Accepted by 3 Date� b Ar Pit or Grout Inspection by S Date Final Inspection by Dat Additional Comments; Applicant - Return all copies to: I Q — SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, p O BOX 2009, 9TOCKTON, CA 85202 ' FEE AMOUNT DUE ` AMOUNT REMITTED GK INFO CASH RECEIVED BY DATE PERMIT"NO. EN 13-24 11tEv.It is sor U 1 •L�l� zG rel