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A APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 9.52011 (209) 468-3447 �t, (Complete iia Triplicate) 44 i��%fIt Application is here°°'''' made to San Joaquin County for a permit to construct and/or install the windribed., This application in me ade in co4liancwith San Jrriquin County !ordinance No. 549 and 1862 and the Rule deRe lntIon3' of Ban Joaquin County Publ!a Health Servicers Job Address City C[x Lot Size/Acreage ,'' W - 2 n Owner's Name &&'J_4Z26 . �riEJ _ Address r- C7~ Phone ( 1 ContractorfaLWA—�A Address 3 s- �LI D License No. � ? Z Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 71 DESTRUCTION ❑ Out of Service Weil ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK /C2 ,� SEWER LINES DISPOSAL FLD./" PROP. LINE _-_-_ FQUNDATI_gN, _AGRICULTURE_INELL�-_ OTHER WELL. _P_IT_5/SUMP_S_�,� - INTENDED USE TYPE OF WELL PROBLEM AREA ` CONSTFWCTION SPECIFICATION !/ n�nduserisl pen Bottom C] Manteca Dia, of Well'ExcavatiarA Dia. of Well Casing Domestic/PrivateGravel Pack ❑ Tracy Type of Casing a(f Specifications M Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout. G Irrigation Approx, Depth Eastern Surface Seal installed by___ -O&E, Repair Work Done L7 Type of Pump H.P. State Work Done } Watt Destruction 0 Well Diameter Sealing Material i Depth Depth Filler Material Z Depth TYPE OF SEPTIC WORK; NEW INSTALLATION 0 REPAIR/ADDITION 0 - DESTRUCTION CI (No septic system permitted if public Sawa( is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms v Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. . ❑ Type/Mfg Capacity No. Compartments f PKG. TREATMENT PLT.-CI Method of Disposal ; Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED (_I Distance to nearest: Well Foundation � Property Line 1 Y SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line z DISPOSAL-PONDS-0 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin courity ordinances, state laws, and rules and regulations of the Sin 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 Certifies the following; "I comity that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion taws of Califor is," The applicant ust . II for re r inspections. Complete drawingon r rse side. f Signed Title- _ � Date: FOR DEPARTMENT USE ONLY Application Accepted by J Date /x Area Pit o rout Inspection by Date -11 Final.Inspection by Date Additional Continents: - Armllcant - te�A= eyll�opiea to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES INVIRONMENTAL HEALTH DIVISION PERU I T/SERVI CES 445 N SAN JOAQUIN, P O BOR 2009, STOCKTON, CA 95201 FEE INFO /ACJMrOUNT D<}E AMO VNT REMITTED CASH RECEIVED By DATE PERMIT NO. 1H 13-24 EH ,1.26IREV.It'Is) Y 9C ,� t Q, —a;33 LO .