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i Y 1 . f APPLICATION FOR PERMIT A71�-. SAN JOAQUIN COUNTY PIMLIC REALTH SERVICES / �W:5 ENVIRONMENTAL HEALTH DIVISION 1601 E. RAZRLTON AVE. , PHONE (209)465-3420 P O BOX 2009, STOCKTON, CA 95202 Te BIs'R1LIT_EILPIREB�, I?ROM Ga,/Vzrr2 (Complete in Triplicate) T� 1 2[n D LA-) ' 4/La ftf.til 44, f5 S Application is hereby grade to Sen Joaquin County for a permit to construct and/or install the work herein described. This application ie made in coarpliance with San Joaquin County ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services, A � E2 , Job Address • • t:'owI _�� E'¢ �Of�2►�j� �QI1� CoCLot size/Acreage f� l��L Sd itr_ .. - � GL SSOcfa S 06Z Al. /9 4• c9✓!x S GoZ-z4Z -z i 4�vnar's/lJante _._ „___ AdAAdress hone I Contract �i21e.�/n/ Address f�"1el � d✓AiGI 5,..,�M CA5 License Nc, Phone -y� � TYPE OF WELL?Pl}MP: NEW OIL WELL ❑ WELL REPLACEMENT M DE5TRliCTION ❑ Cut of Service Well PUMP INSTALLATION C SYSTEM REPAIR O OTHER Q rronl1torTrig Well DISTANCE TO NEAREST: SEPTIC TANK N SEWER LINES DISPOSAL FLDt_Zd— PROP. LINE FT. FOUNDATION AGRICULTURE WELL!,,,,,. - OTHER WELL„_,,, PITS/SUMPSA�/.4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O%xf C.) Industrial C Open 9ottom G Manteca )(Dia, of Well Excavation 67rvy Alevisf Dia. of Well Casing 7- 17) Ill Domestic/Private [i Gfevel Pack L7 Tracy Type of Casing VG Specifications- i'I Public Iii Other fl Delta Depth of Grout Seal -4 FEET XType of Grout-2 I I Irrigation __Approxi Depth I. I Eastern Surface Sabi Installed by 1 Repair Work Done U Type of Pump H.P. State Work Done Well Destruction a Well Diameter [Sealing materialilli Depth U f Depth Piller Naterial i Depth 0 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIAODITION t ! DESTRUCTION I I (No septic system permitted it public sewer is available_within_2CO feet.I —0*081idn w@I i rve: geiidariee-, Commercial— Other Number of living Unita: Number of bedrooms _ a Character of salt to a depth of 3 feet: _._ Water table depth SEPTIC TANK fa type/Mfg _-- -- Capacity.—�. No. Compottmpnts PKG, TREATMENT PLT, 0 Method of Disposal Distance to nearest: Well Foundation_ Property Line LEACHING LINE 0 No. 8 Length of lines „ Total length/size FILTER BED 1-1 Distance to nearest: Well Foundation Property Line_ SEEPAGE PITS 1 ) Depth Site Number SUMPS LI Distance to nearest: Weil_ 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 isws, and` rules and regulaz}ons of the San Joaquin County Home owner or Iicanaad agent's signature Certifies the folloWng: "t certify that in the performance of the work for which th;s permit is issued. I shall not employ any person in such manner at to become subject to workman's compensation laws of California,"Cantractoes hiring or subcontracting signature certifies the following: "I Certify that in the performance of the woek for which this permit is issued, I shall employ perform subject to workman's compensa- ti0n laws of California." The applicant must coil for all required ins coons. Complete drawing an reverse side. f��39p / si$"od K Title: t2TECT N Foie k,� tiE7-- .g ocr� S Date: FOR aEIpARTMEAIY USE ONLY Application Accepted by, Data +Area - Pit or Grout Inspection by Date r,.� Final Inspection by `- "r�0ette �O� 7 D Additionai Comments; Applicant - Return all Copies t04 San Joaquin County Public Health 8ervioesr Raviroamental Fealth Permit/9ervieea 1601 E, Hatseitota Ave., P G Sox 2009, Stockton, CA 95201 FEE AMOUNT pyE AMOUNT REMITTED CK RECEfVED !!Y iaATE PERMI-1"ND, INFO CASH . EH I2•24 Inv,r/110i �G� ertiM71 ■1d 6Ei 06ib /SO �� f � 76 3�0 WOZj