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APPLICATION FOR PERU-IT SAN JOAQUIN COUNTY l PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 lb PERMIT EXPIRES 1 YE FR M DATEISSUED - (Complete in -Triplicate) Application is hereby made'to San Joaquin County for a permit~to construct and/or install the work herein described. This application�Aa.smde,in.cea Mance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and RegulAtions of San Jotu)uia County Public Health Services. ^ Y. Job Addressfl ' -•__ Q S ��CJ Ciry Lot Size/Acreage Owner's Name, Address Phone Contractor Lt4 Address Z/4940-License No. Phone r '�s/- TYPE Of WELLIPUMP: NEW WELL, WELL REPLACEMENT DESTRUCTION ❑ Out of Service Yell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well. L3 DISTANCE TO NEAREST: SEPTIC TANK ZM SEWER LINES DISPOSAL FLD. Z22 " PROP. LINE i - - - — -�- FOUNDATION_ ;AGRICULTURE WELL OTHER WELL _ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ::Rf7 - Dia. of Well Casing )d Domestic/Private 0 Gravel Pack )'Tracy Type of Casing__. -- pi`46 Specifications /& t I'I Public El Other fl Delta Depth of Grout Seal ; 1Type of Grout.- /� f i 1 Irrigation ,�IP �Approx. Depth [ ( Eastern Surface Seal Installed by Repair Work Done 0 Type of Pum H.P. State Work Done Well Destruction ❑ Wall Diameter Sealing.10"rial i Depth Depth Filler Material i Depth Gy TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION t•I DESTRUCTION l I (No septic system permitted if public sewer is A available within 200 feet.) Installation will serve: Residence_-__, Commercial-__,_ Other Number of living units: Number of bedrooms Character ofrsoll to a depth of 3 feet: s A Water table depth SEPTIC TANK. _ ❑ Type/Mfg Capacity No. C PKG. TREATMENT PLT.❑ Math o i " Distance to nearest: Well Foundation Property Line RE EIVED LEACHING LINE ❑ No. a Length of lines Total length/size FILTER BED ❑ Distance to nearest: Wall Foundation properW N JOA' IN L;au i fy F'' mss" SEEPAGE PITS 1-1 Depth Size Number SUMPS U. Distance to nearest: Well 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 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,1 shall employ persons subject to workman's compensa- tion laws of Califfrnla." The applica at call for ail requir i spections. Com to drawing on grside. Signed + . ills: Date: R,DEPAUSE ONLY Application Accepted by Date a Pito out napaction by DataFinal Inspection by Data✓' Additional Comments: 1ct t n� �etrx�l�r�„ If stu ffs. kt-k,rd- W6' to-i/As, 14 ni, s Applicant - Retur all copies to: San Joaquin Count'y Public Health Services r6tG- Co-Au ' t'rvr.- O Y Environmental Health Permit/Services / 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 t FEE AM;6UE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO • EH 14-21 TREY,t i K 41 //�/"7 l r� y`Z ! G1.� `d p EH 1425