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it APPLICATION '1 SANI�AAQUIN,il COUNTY, PUBLIC HEAT TH RVICES ENVIRONMENTAL HEALTH DIVISIONis . 445 N SAN ,IJOAQUIN; PHONE (209)468-3420 ` P, O BOX 2009, STOCKTON, CA 95201° _. . PERMIT EXPIRES 1. YEAR FROM 'DATE ISSIIID (Complete: in Triplicate); II �i.` � k-` Application is hereby made to San Joaquin County for a permit to'construct and/or install the work hereindescribed. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the'Rules and Regulations. of San Joaquin County Public Health Services. �(� IT, < t sI _ City SIC) . Lot Size/Acreage Job Address 1 x II yy{ o N �t�;�tP y, �. 3i ��a3� 3 `/- Ys(;:7 j Owner's Name r� ?rfl� "t 4 k Address $�.�`l � �c d'. as �1' 'Phone F ,;♦11 Address o70s—,AM' 'i��on License No.�'��I,�Phos Contractor 's !++^ - r TYPE OF WELL/PUMP: NEW WELLW .j. WELL REPLACEMENT Cl DESTRUCTION ❑ Out, of, Service Well ❑ PUMP INSTALLATION ❑ /IIA SYSTEM REPAIR ❑ !i OTHER C &lonitoring.Well ti 1 DISTANCE TO NEAREST: SEPTIC TANK �� SEWER LINES �� :DISPOSAL FLD'. PROP. LINE j FOUNDATION- Ip' AGRICULTURE WELL OTHER:WELL PITS/SUMPS INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 r !! ❑ Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation r � Dia. of Wail Casing (:3 Domestic/Private L-1GravelPack L3Tracy Type of Casing-_P�i�� Specifications Q I'I Public is Other i;i fl Delta j Oepth of Grout Seal f� - _. Type of Grout e,& I I Irrigationrface S Approx. Depth I 1 Easte±n SSeat Installed by cel U I a Repair Work Done U Type of Pump Y Ei H.P. Stat j Work,D;ne �T Well Destruction O Well Diameter Sealing.Jwlaterial iDepth e e ��c7 v7 Rt'�ins? :A 11^"S1 Depth y �� Filler MpteriaT d Depth f` e '("CAF / s"( / XA IC W RK: X TION I EPAIR/ADDITION {':I DE TRUCTION I t'ihlo p.tic sy em permitted if pu 'c sewer is avai le within. 00 feet./ �? wit erve: 'Rmarcieii Other ;; G ' Ing units: f bedrooms ii , cot! to a depJ; Water table depth ❑ i Capacity• No. Compart is E PLT. ❑ Method of osal;I. °larest. Wel Fou scion Prope Line L CHING LINE No. & LenX Total len /FILTE BED _ Distan to Foon Property LiSEEPA PI 1 1 e h u er i n Ito Fou anon SU S D stn SPOSAL PONDS ❑ � I hereby cartify that l have prepared this application and that the work will be done in accardance with San!Joaquin county ordinances, state taws, and _ rules and regulations of the San Joaquin County ' Home owner or licensed agent's signature certifies the following: '9 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 toworkman'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 compensa- tion laws of California." The applicant must call for all s. Complete drawing on reverse side.' Signed X l Title: S, '-' 'Date: FOR DEPARTMENT USE NLY. , � Q a y iienj;q" €i D !� " Application Accepted by ate Area Pit or Grout Inspection by Date Final inspection by Data I I y Additions! Comments: /t Applicant - Return all copies to:. Sart Joaquin County Public "Health Services � 3 Environmental Health Permit/Services i 445 N San Joaquin, P O Box 2009, Stkn; CA 95201 J, INFO AMOUNT DUE'' AMOUNT REMITTED CK CASH RECEIVED BY OATE PERMIT'NO. u r FH;3-24Il t{ $—15)