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APPLICATION FOR PE SAN JOAQUIN COUNTY PUBLIC 11906�tXi �/(/ 445 NSAN JENVIRONMENTAL IN, HEALTH 2 DI V91ff3%3d9n G tr P O BOX 2009, STOCKTON, Qr�}jj {{��d2f]1 PFIWIT EXPIRESYEAR R Y (Complete in Triplic t Application is hereby made to Ban Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban Joaquin County Public Health Be ces. Job Address / 2 `1 f' k-i( City S � I Lot Size/Acreage ,X Owner's Name/�`97nc(Z Address Phone 4i �(ac /�.k Address ,,�' eV�_fl �L / Gf"+-� License No. 3/,S7 7 Phone d �n � 0 Contract / �� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Cl Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications \ I'I Public (-I Other fl Delta Depth of Grout Seal Type of Grout I I Initiation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Ontructlon ❑ Wall Diameter Sealing Material A Depth Depth ller Material a Depth EP TYPE OF SEPTIC WORK: NEW INSTALLATION I RAI ADDITION DESTRUCTION I I (No septic system permitted it public sewer is available within 200 Intl Installation will "rve: Residence Commercial_ Other 1 Number of living unite ---L Number ofs Character of soE to a depth of 3 fast, V Water table depth SEPTIC TANK Type/Mfg hT1 'tit —t Capacity T /� L No. Compartments PKG. TREATMENT PLL Cl [''1� r I Method of Oisrosal �\ Distance to nearest: Well fI Foundation _ Property Line LEACHING LINE No. g Length of lines ". Total length/size T FILTER BED 0 Distance to morest: Well ' r Foundation _ 0 Properly Line -F n If rV1 SEEPAGE PITS Depth -r .5 Size �t yumber —� f 7 SUMPS LI Distance to rte•rest: Well � Foundation 1 C -I Property Line 5 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 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 not employ any person in such manner as to become subject to workman's compensation Is"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 shell employ parsons subject to workman's compenu tion lows of California." The applicant NI for all r in tans. Complete drawing on rover"•id . (' l Signed 'Ll ��' � L e _r< Tithe: r Date:r _J ' r FOR DEPARTMENT USE ONLY / Application Accepted by Data ( � - Area 2- Off Grout 1 7 rupectbn by ate Final Inspection by��d'T-fiir� Date 5 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 995 N San Joaquin, P O Box 2009, Stkn, CA 95201 IFEEEq AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. °Y t?Ie MEV.t f tiJ /� IN, Z f 35 l 3 -3 IH 14-M