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74, APPLICATION 1 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 144 ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 € P O BOX 2009, STOCKTON, CA 95201 1; a ,I PERMIT EMIRES Z YEAR FROM DATE ISSUED -` (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 is made.in c6n liance'with San Joaquin County Ordinance No..549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address ,3b ore .FI City b Lot Size/Acreage Owner's Name• W Col rt 5 Address o�70 q f r l Weir, ,5Ph Phone Contractor flcjt?r M' Address rA,n,<:-AVog2ly..;rir:nse No. � yHbl j phone 'y A TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 171, w DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C1 OTHER aa Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLA. �e°f� bP�LIFfE� W11 FOUNDATION. AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS + M Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation !1 -- .,� Dia. of Well Casing C.l Domestic/Private 0 Gravel Pack 1- O Tracy Type of Casing_ "" Specifications I"1Public 1.1 Other fl Delta Depth of Grout Seal - �. — Type of Grout I S Irrigation ; _Approx. Depth I i Eastern Surface Seal Installed by i-axi*&,fiY Repair Work Done L3 Type of Pump H.P: State Work DoneNJ e � e Well Destruction ❑ .;,Well Diameter 1 "' 1 Sealing Material & Depth i I ,Depth f Filler Material & Depth TYPE OF SEPTIC WORK: :NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is t available within 200 leet.) Installation will serve: Residerice_ `Commercial_ Other Number of living units: Number sof bedrooms t3 M Character of soil to a depth of 3 feet: ! Water table depth SEPTIC TANK O Type/Mfg 't Capacity No. Compartments PKG. TREATMENT PLT. 0 r Y Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE C) No. & Lengthi of lines Tota! length/size ° FILTER BED ❑ Distance to nearest: Wel! Foundation Property Line S� 1 r SEEPAGE PITS 4 I Depth Size Number SUMPS CI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS -❑ I 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 cenifies the following: "I certify that in the performance of the work for which this permit is issued, 1 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, I shall employ persons subject to workman's com tion laws of California." pensa' I The applicantcall for a!! uired inspections. Complete drawing on reverse side. g Q �3i7G,. - i Si ned Title: 2 Date: 7 9 � F R PARTMENT USE ONLY Application Accepted byDate '_ 3 f Area 5 Pit or Grout Inspection by Date Final Inspection by Date_ !!`93 Additional Comments t Applicant - Return all copies to: San Joaquin County Public Health Services 4i Environmental Health Permit/Services i 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. M • EH 13-1 tREV.t i x sl �j t r p r Q?