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6r APPLICATION �-, /( / SAN JOAQUIN COUNTY PUBLIC ERV ICES� ENVIRONMENTAL AF AT.TH IE N SAN JOAQUIN, PHONE 2)qt -3420 P O BOX 2009, STOCKTON, PERMIT EXPIRES 1 EAR FR SM (Complete in Tripli a # l Application is hereby made to San Joaquin County for a permit to conatruc a / Ens ascribed. This application is made in compliance with San Joaquin County Ordinance No. 54 2 and the Rules and Regulations of San Joaquin County Public Health Services. n Job Address &9Z01 44a� .�7 �s-^- Pi City, v Lot Size/Acreage Owner's Name �c��s'.--- `- Address � 'A"'� Phone Contras � '��eL`—d7e►�-c Addres� to t�� License Z' Phone 30 TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT Cl DESTRUCTION Cl Out of Service Well 0 PUMP INSTALLATION G-'-' SYSTEM REPAIR P--' OTHER ❑ Monitoring Well C] DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _— DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F Industrial ❑ Open Bottom C Manteca Die. of Well Excavation Dia. of Well Casing omestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications I'1 Public 1-1 Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation /— Appeor, Depth I I Eastern Surface Sed! Installed by Repair Work Done !�l Type of Pump, H,P. �is1�-�-� �_.� State Work Done ��.. ^ .e iO Well Destruction O WeN Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDIT}ON 1 i DESTRUCTION 1 1 (No septic systam permitted if public sewer is avaitable within 200 feet) Instadstion will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet. Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method cf Disposal Distance to nearest: Well Foundation Property Line PAYMENT LEACHING LINE Cl No. S Length of lines Total length/sizeRECEIVED FILTER BED ❑ Distance to nearest: Well Foundation Property Line ---AU" 0 1993 SEEPAGE PITS I I Depth Size Number SAS SUMPS LI Distance to nearest: WeN Foundation . Property LinePUBLIC I - DISPOSAL PONOS ❑ ENVIRONMENTALHEALCN�,�'�'_• I hereby cenify that I have prepared this appl-ication and that the work will be done in accordance with San Joaquin county ordinances, state laws, an rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I cenify that in the performance of the work for which this permit is issued, 1 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 cenify 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 mu or MI requir peclions. Complete drawing on re se side. Signed x Title: A Date: i FOR DEPARTMENT USE ONLY Application Accepted by 0itn AA " Date I— Area PN or Grout Inspection by Date Final Inspection by Data /b Additional Comments Applicant - Return all copse to: San Joaquin County Public Health Services Environmental HealthPermit/Services 3 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED C H RECEIVED B DATE PERMII NO, 1 INFO (,()/��) y/]J •//�"y) 9 EM U-21 IREV. in ni`PIr /TW "`� 1 c `I 3 / " / I EK t�.a6 , Y`�