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APPLICATION it SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES r ENVIRONMENTAL HEALTH DIVISION - 445 N SAN JOAQUIN, PHONE (209)46$-3420 PO BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Joaquin County for a permit to construct and/or install the work herein described. Application is heresy made,to San This dinance Na. 51+9 and ]662 and the Rules and Regulations of San application is,made in compllancriwith San Joaquin County Or Joaquin County Public Health Services. } City T^^dGp Lot Size/Acreage Job Address ;. i Owner's Name` aures E. Messick Address 1437 W. Etitclid Air -- _ . Phone p� O.BOX 64 Llrlde>1 License No. 3779?3— 9 phone — ConlraCfOrtrtllance Drilles Inc-Addy TYPE TF—WE LLIPUMP: NEW WELL 2 WELL REPLACEMENT C7 DESTRUCTION Li out of Service Well OTHER ❑ monitoring Well 0 PUMP INSTALLATION�9) SYSTEM REPAIR ❑. `'- SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK FOUNDATION __ — AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1?; Open Bottom ❑ Man Dia. of Well Excavation Dia. of Well CasiDgy — n industrial x. t! Specifications w Type of Casing_--- (:] Domestic/Private ❑ Gravel Pack L7 Tracy Type of Grout El Other n Delta • Depth of Grout Seal ,;�._.—...�� — i ['I Public Surface Seal installed by I. Irrigation 41%Approx..Depth I I Eastern Repair Work Done 0 Type of Pump — H P State Work Dane Sealing Material & Depth- Well Destruction ❑ Well Diametr Filler Material & Depth h Depth I I DESTRUCTION I i TYPE Of SEPTIC WORK: NEW INSTALLATION 4 I REPAIR/ADDITION I afvailablr ewithin 200 feet.) if public sewer is l Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms i Water table depth Character of soil to a depth of 3 feet: -^'° ^-"`""Na�Compartmenta Capacity° _�«� SEPTIC TANK ❑ Type/Mfg Method of Disposal PKG. TREATMENT PLT. 0 .•. Property Lina Distance:to nearest: Well Foundation Total length/size LEACHING LINE ❑ No. & Ltsngth of lines Property Line FILTER BED 0 Distance to nearest: Wel! Foundation " Number SEEPAGE PITS 11 Depth Size, Property l ine SUMPS LI Distance to nearest: Wall Foundation-��—^ DISPOSAL PONDS ' D } ill be dons in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared this application and that the work w rules and regulations of the San Joaquin County following; "I certify that in the performance of the work for which this permit is issued, 1 shalt not Home owner or licensed agent's signature certifies the 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 per subject to workman's compensa tion law,,of California." The all st call f�al 'red inspections, Complete drawing on reverse side. # .f/ sty Dete:. Signed X_ for Title: _ f F DEPARTMENT USE ONLY Date _ Area A Application Accepted by ' Date S 9� Final Inspection by - Dete [ Pito Grou Inspection by if Additional Comments: t 7 l rEa Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 CK RECEIVED BY DATE PERMiT'NO. FEE AMOUNT DUE AMOUNT REMITTED CASH IN� �- 2-0 1 EK 13-24(REV.I/x S1 W i 'EK 14.20 _ _