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tµ APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 A -7 -YEAR PROM DATE ISSUED qw, /ff.-d t/,lo t1n;tpinanc4elth (Complete in Triplicate) Appli •tion is herebquin County for a permit to construct and/or install the work herein described. This ation is made San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin Count Public Health elSSeervice fig) %,Job Address r '� eL�City Lot Size/Acreage Owner's Name 54,`r J- 040at/t'-/ euN ddress Phone !' �r' 5 O Contractor Y( Address, " rt`E!` ' S7— `wCr,/ License No. S 2O 6y Phone 11�?13YA TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well Cl PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Monitoring well _r 57 rn1 GS DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ZZ)t-, FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPSP INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ( Dia. of Well Casing U Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public 1-1 Other 0 Delta Depth of Type of Grout Mi Irrigation ,_-_. Approx. Depth ❑ Eastern Surface Seal Installed by Af mu P&m-_ Ry ALES Repair Type of Pump H.P. State Work pone �t Q_ air Work Done U T yutv r Weft Destruction ❑ Wait Diameter Sealing Material 4 Depth ""EpkpluG'I /,C� c7Lu Filler Material i Depth 57VCorcAA Depth ; TYPE OF SEPTIC WORK; NEW INSTALLATION ❑ REPAIRIADDITION 0 DESTRUCTION CI (No septic system permitted if public sewer is 24 available within 200 feet-I installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. b Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS Ll 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 mariner 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 shali employ persons subject to workman's compensa- tion laws of California." The sppficant must ii for all r, uirsd ins c 'ons. Complete drawing on reverse side. Signed f Title: Dere: I Y4 FO DEP TMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments; af►' ' 4 3 Wl uL" � _ Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES` + ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES i 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201FEE 1 INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PEAMl7'NO. Q p� . EH EH A 1]-2e 24 IREV,riN5i [ L i