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I J APPLICATION, FOR PERMIT r 6 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVVISION' 95201 P 0 BOS 2009, STOCgTON, (209) 468-3447 Y i (Complete in Triplicate) in e to son Joaquin County for a permit tonstru549Aa install eore A 1662 land theRua andRegulationsdof Sana Application is hereby zttad compliance with San Joaquin County Or inanc � spplicstion is made in comp ..�� Joaquin county Public Health Services. ] n�Z Lot Size/Acreage �Q city - Jab Address � f� phone � l Address Owner's Name t IC , �/ Phone Addresses a ,e�C License Noc DESTRUCTION Cl`Out of Service well Contractor WELL REPLACEMENT CIS" OTHER O MOnitorin$ Well L7 STYPE OF WELLIPUMP. ; NE WELL ' � y 1"� SYSTEM REPAIR L7 PROP. LINE PUMP INST4LLATION MQ j DISPOSAL FLD.�— IW SEWER LINES -- —' OTHER WELL PITS/SUMPS __f DISTAtJCE'TO,NEAREST: SEPTIC TANK AGRICULTURE WELL Il FOUNDATION b TYPE OF WELL PROBLEM AREA, .CONSTRUCTION SPECIFICATIONS Dia of Well Casing INTENDED USE +Dia..of Well Excavation ClOpen Bottom 0 Manteca _Ni. .� Specifications �[1 n tndustriet 0 Tracy Type of Casing Type of Grout 1! 0Domesticl Private Gravel Pack a � l 11 Other ❑ Delta Depth of Grout Seal -= Q public �Surface Seal Installed by ` CI Irrigation aT�Approx. Depth ❑ Eastern State Work Done TYpeIof Pump H.P. �--1 Repair Work Done (3 gent Ing lteterial L Depth Weil Destruction D Wall Diameter _.�--- Filler Material i Depth t Yf Depth - available within 200 feet.) + TYPE Of SEPTIC WORK; NEW 11,;S1REPAIRIAODITIQN L1f DESTRUCTION CI lNo septic system permitted if public sewer is � '-,,Installation will serve: Residence Commercial_ Other.ter Number of living YIr a: Number of bedrooms -- Water table depth Character of soil to�a depth of 3 feet: Capacity No, Compartments SEPTIC TANK. 0 TypelMfg Method of 04posal f PKC. TREATMENT PLT.0 * I ;.,, Foundation s- Property Line Distance to nearest: Well Total length/size LEACHING LINE 0 No. & Length of lines l_ FILTER BED [1 Distance to nearest: Well_ _. _ Foundation � Property Line , - i t t Number Size t' SEEPAGE PITS I I Depth Foundation-- Property Line w SUMPS LI Distance to nearest: Well DISPOSAL PONDS O I hereby Certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws. end rules end 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 shell not P employ any person in such manner si to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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 compenss _ti. I i tion laws of Californis." The applican o life tions. Complete drawing on eve std aide., f f r- Date: ! .• s Title: '� - --- _ i Signed FOR on USE O LY -r t - t kAl Atillre Application Application Accepted by ' ', s� ,.►_ Data t Date ' Final Inspection by v ;. t Pit or rf t Inspection by t Additional Comments: r Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN,..P O BOX,2009, STOCKTON, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED - Cg5H RECEIVED BY DATE PERMIT NO. b INFO t ., .. JK� - -� CO) 38 �. . EH 13•74 IREV. M 5� , 5 '` 1`30 91 — EH 14_ia