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APPLICATION FOR PERIL[I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 M 1_ Y}EAR „-i'Rou DATE„I SSrnzn (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described This application is wade in compliance vith San Joaquin County ordinance No. 5L9 and 1862 and the Rules and Regulations of San Joaquin County Public Health services. ,�17 Job Addrsaa __ //'/ City_ Lot Size/Acreage Owner's Name � -�,> AgAosddress Phone �— Contractor ddress License No. ool Z Phone TYPE OF WELL/PUMP. NEW WELLX7 WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well Cl PUMP INSTALLATIOf ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ~� ILA ,?'`—,�—/— PROP LINE � FOUNDATION V AGRICULTURE WELL � OTHER WELD PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j !P [I Industrial ❑ Open Bottom © Manteca Dia, of Well Excavation Dia. of Well Casing amasticlPrivate ,I `Gravel Pack ❑ Tracy Type of Casing _421Specifications M Public 1.1 Other p Delta Depth of Grout Seal Type of Grout veli 1 ['J Irrigation �-^—*-�— _Approx�Depth ❑ Eastern—, rface-Soul-Installed'by ---- Repair Work Done 0 Type of Pump �� H,P, "/ .? State Work Wolf Destruction ❑ WeII;Diamater l �, . sealing.Material 6 Depth ' Depth Filler Material it Depth TYPE OF,SEPTIC-WORK;ANEW-INSTAEL•ATiON- •.,-REPAIR/ADDITIeN-M;DESTRUCTION-El-•{No-sepiic-system-permined'if pir6lic sewer is l/� 's f r. available within"200"leet.l Installation will serve: Residence-_„ Commercial T,- Other t ~"Number of living units: Number of bedrooms f'"" �' NJ Character of soil to a depth of 3 feat: Water(table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Cort'tpartments PKC. TREATMENT PLT. 0 I -------� Method,Of Disposal Distance to nearest: Well Foundation Property Cine.`' v LEACHING LINE ❑ No. b Length of lines Total length/size FILTER BED n Distance to nearest: Wall Foundation Propony.Line SEEPAGElPiTS 11 Depth Size ' - SUMPS F Number Cl. Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby comity that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rule's 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 manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature cerlifies the fallowing: "I comity that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's com ansa- tion laws of California." The applicantg (12 c o I Or t' Complete drawing on revsr side. r �t 1 Si'A ed tle: Date: ,Z ;/� Ulm FOR DEPARTMENT:USE 04Y Application Accepted 4by % Date 3 Area Pit or Grout Inspection �� / .2 Final Inspection by �� Date 7 �, r _P /1J.9 1 -Ir t M Additional Comments: r �,e Applicant - Return allcopies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES —7;t �E� z� .31 445 N ENVIRONMENTAL HEALTH DIVISION JOAQUIN, P 0 BOX2009.STOCKTON, ES 95201CI CG �.r �5 d FEE AMOUNT DuE AMOUNT REMITTED CK - - .. " P� INFO CASH RECEIVED BY PATE PERMI7"N0. r�Y1 y + EH 1744 IREV.a/A 51C3 nit P 10 f