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{ ] APPLI CAT_I OR_-FOR PEP-MIT SAN .IOAQUIN COUNTY .PUBI.IC.-.HEALTH .SERVICBS. • r ENVIROXICENTAL SEALTHDIVISION �I �- II P O BOX 2009, STOCKTON, CA 95201 (209) 468-..34,20 OCT 0 5 1995 NVIRONMENTAL HEALTH i (Complete in Triplicate) PERMIT/SERVICES Application is hereby me.dc to Ban JoaQuin County ror a permit to constructand/or install the Work herein described. This � apPlicatioo is made in cePullance vith Hatt Joaquin County Ordinance No. 5L9 End 1862 wad the Rules sad Regtslatlon6 of San Jcaquia tounty Public Health Seryieea. f�Or/4>Fr�r C�46 JOD ACore3s r/'e / _Z0,04( ,Lot Size/Acres.ge I / Owner's Name -7— Address 1'd 3 3_W (.I2ri O.So !`xsso Contractors address /G w License No.7IGS'!ofi Pnone( TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION Cl Out of Service We11 Cl PUMP INSTALLATION 0 SYSTEM REPAIR G OTHER J9 Hg nitoring Well �7 so.lirwofrr rpbew DISTANCE TO NEAREST: SEPTIC TANK _ /!!/G SEWER LINES P „ DISPOSAL FLO. ,!� PROP. LINE _� FOUNDATION L& AGRICULTURE WELL eZe4:_ OTHER WELL O' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f.7 lndusui+l O Open Bottom ❑ Manteca .4 - Dia. of Wall Excavation 2r Dia. of Well Casing Alan CKI DomesticlPrivate . Cl Gravel Pack O Tracy Type of Casing126 Specifications 0 Public '1 IX Other ❑ Delta Depth of Grout Saal S'(!� Cf Type or Grout !rM1,l7' Cl lri-Udoon 2M.Approx. Depth ❑ Eastern 5urfice Seat inslalitrd by Wall Work pane U Type of Pump H.P. State Work Done ucSealing KaLterlal L Depth Wall Destrtion 0 Well Diameter P `k Depth filler 1laterial i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRlAbDIT10N Cl DESTRUCTION CJ (No septic system permitted it public sewer is i available within 200 1601.1 Instillation will serve: Residence _ Commsrc;sl_ Other k tis i .Number of living unite Number of bedrooms Character of soil to a depth of 3 feet: --Water table depth SEPTIC TANK O Typa/Mfg capacity_, _, No. Compamment3„ ?KG. TREATMENT PLT. D Maihod of Disposal Distance to nearest: Well Foundation Propeny Line ',EACHING:LINE C1 No. E Length of tinea Total Iangth/size =ILTEA 9ED ❑ Distance to nearest: Well Foundation _ Propeny Line SEEPAGE PITS i I Depth Sita _ Number Y SUMPS Ul Diitance to nearest: Well Foundation Propeny Line w, J DISPOSAL PONDS C) I , I hereby certify that I have prepared this application and that the work will be done in accesp;,nce. with San Joaquin county ordinances,.SIM laws, and ivies and regulations of the San Joaquin County Home owner or licensed agent's signature cartifies the following: "I certify that in the ponormanca 01 the work for which this permit is issued, Ishslt not employ any person in such manner as to become subject to workman's compensation laws of Catilornia." Contractor's hiring or LUb-COntratling signature cartilias th+ lollowing: "I canify that in she performance Of the work for which this permit is issued, I shalt employ persona subject to workman's compensa• :ion laws of California." The applicant m ct call I r all required inspections. Complete drawing on reverse side. I signed Title: 0'2 � Data: �l�,�- - lz I FOR DEPARTMENT USE ONLY Applicslion:Accepted by ,F �' ' 'I Date ! Area. ?it or Groul Inspection by Date Final lrtcpection by Date A6dillonal COM rMnta: A Applicant,- Return all 00 les to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL IIEALTH DIVISION PERUIT/SERVICES 445 N BAN JOAQUIN„ P O HOX 2009, STOCKTON, CA 95201 2�0� FEE AMOUNT DUE A OUNT FtEIMAITTEO C INFO RECEIVED gy DATE PERM11'NO.