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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH�SERVICES ENVIRONMENTAL fEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 iEAR PROK—DAIR (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.caopliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health'Servlces. Job Address �J `�, r ��G�- City r4G Lot Size/Acreage Owner's Nems r" f +✓. r"a UG r g Address Gf!7S �• `J e�"�G Phone S�fO apb I: Contractor S G _ ddress ZS ZS j,_ M�ipl_lG.—License No. 51LZG Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT I f DESTRUCTION Out of Service Well Cl PUMP INSTALLATION•❑ r SYSTEM REPAIR D „4 OTHEA ❑ Monitoring well DISTANCE TO NEAREST: SEPTIC TANK >2.4DO SEWER LINES > 4,90 r DISPOSAL FLD, 4114 PROP. LINT: 7L� FOUNDATION AGRICULTURE WELL A441. OTHER WELL 9' PITS/SUMPS A1114 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS N fl Industrial LIOpen Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private 0 Gravel Pack Tracy . Type of Casing Yr1 b Specifications El Public I:1 Other ❑ Delta Depth of Grout Seal t Type of Grout$� n M Irrig5lion �Approx.,Depth. Cl Eastern k Surface Seul Installed by Repair Work Done 0 Type of Pump H.P. State Work pone _ Well Destruct X Well Diameter 3ea11ng Material k Depth - 4�ts:S$ra�E roa Depth I Filler Material i Depth `\ TYPE OF SEPTIC WORK: NEW INSTALLATION G REPAIRIADDITION 0, DESTRUCTION G {No septic system permitted if public sower is C available within 200 feet.) Q Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms ' . Character of soil to a depth of 9 feet: r Water table depth SEPTIC TANK. O Type/Mfg} Capacity No. Compartments PKG.�TREATMENT PLT. Cl Method of Disposal 1 Distance to nearest: Well Foundation Property Line U LEACHING LINE ❑ No. A Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line �- E f f SEEPAGE PITS 11 Depth I Size Number - SUMPS U Distance to nearest: Wail 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 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 notes ` 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 compansa- il tion laws of California." The eppfic m t call for all req 'red ' s i s. Complete drawing on reverse side. S Signed Title- . jW • Date: Al � b F FOR DEPARTMENT USE ONLY Application Accepted by Date Area [ 3 o . P1 or Grout Inspection by Date T Fina! Inspection b� y Date9 ko p Additional Comments: 1 ` i — Applicant - Return all copies to; SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES a ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 1445 N SAN JOAQUIN, P O BOX 2049, STOCKTON, .CA 95201 INFEE FO AMOUNT OL1E .} AMOUNT REMITTED CASH RECEIVED 8Y DATE PERMIT NO, 001/- 15S3 . EH 13a4 IRS. EH �.3a