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!i APPLICATION, FOR PBR1dIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL-HEALTH DIVISION P O BOX 2009, ' STOCKTON, CA 95201 (209) 468-$447 PWWIT MIRES 1 YEAR FROM DATE ISSUED (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 mage in compliance with Son Voaquin County Ordinance Ito. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health 8ervi es. ' Svc�"tx 1(i ( 'Doi at S}- " Aar�"1: �r C•� �r We Job Address eu�r -4 K S{' City Dt Lot Size/Acreage r `2O` . Owner's Name �' �'� - '� w 1^ Address Phone R371 ( =� itis V10" �75A,lnC) ego �`� �tiAc SdtD u l� �{r� Contractor - [, wo� �#A�ddress �.c:t�-�_C A JVk1?:L— License Nod 1 3 7 2, Phone 7� ��j}� TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER © Monitoring Well vi DISTANCE TO NEAREST: SEPTIC TANK 41oW4, SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ZI 1 0 h 0 Industrial ❑ Open Bottom ❑ Manteca :Dia. of Well Excavation Dia, of Well Casing iT1 kJ I�f Domestic Privet C7 Gravel Pack ❑ Tracy Type of Casing S'L-1 L Specifications M PublicWa 1?Q ther/N-10.� L7 Delta Depth of Grout Seal Typ of Grout G Inigauon �„ Approx, Depth ❑ Eastern Surface,soul Instilled by-Q;J1(-1114 � Repair Work Done 0 Type of Pump &2h2e H.P. V1lneSlate Work Done _ 0114P r Well Destruction ❑ Well Diameter Sealing Material i Depth Depth tiller Mstertal i Depth n TYPE OF SEPTIC WORK; NEW INSTALLATION I] REPAIR/ADDITION❑ DESTRUCTION GI INo septic system permitted if public sewer isf available within 200 loot.) Installation will serve: Residence— Commercial— Other Number of living units. Number of bedrooms V Character of $oil to a depth of 3 feel: Water table depth SEPTIC TANK ❑ TygelMlg Capacity--------.,:— No. Compartments PI(O. TREATMENT PLT. LI Method of Disposal Distance to nearest:' Well Foundation Property Line i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED C. Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS L1 Distance to nearest: i Well Foundation Property Line 1 DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rubs and regulations of the San Joaquin County Horne owner or licensed agent's signature conifias 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 subjecl to workman's compensation laws of California." Contractor's hiring or sub-conuacting signature certifies the following: "I certify that in the perlormance,of the work for which this permit is issued, 1 ahatl employ persons subject to workman's compensa• S tion laws of California." The applca ust "if r I required 'ns, pections, Complete drawing on re or" side. Signed i2�t ([s✓� -- Title: �E/�eo�vFi(,S _ Date: a �) f / FOR DEPARTMENT USE ONLY Application Accepted by _T��✓� _ Date A 0 . Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: C�Ap1�T Applicant - Return all Copies to: 1%SAN JOAQUiN COUNTY PUBLIC HSAC' CAUNTY'PUBLIC HBALTHSERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT MSNTALHSALTHDIVISION 445 H SAN''JOAQUIN,"'P 0 BOX 2008, STOCKY Tel C 2 1 INFO FEE AMOUNT DUE AMOUNT REMiTTEO K CASH RECEI a 41.4 JL � • EH 324111EV,iinsi 4