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a APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES c`p IRONYENTAL HEAL ISION WE �1 AN JOAQUIN, PHONE (209 8-3420 �D �DDJ P BOX 2009, STOCKTON, CA 95 1 FARC f_ FROM D h J gv. (Complete in Triplicate) nwaon `s hereby as an Jcequin ty for a permit to construct and/or install the work herein described. This coequin County Ordin►nce 110. 549 and 3862 and the Rules and Regulations of Ban NPs+ tri 3 —els•? —02-7 Job Address City _ fi�t Site/Acreege lvD g TT•+ tl.�l �� AVMS . Or's alerts I,N�V1 'Y1v�_ Address �r �A '1 ( � wne - �D� _ Pllgne - Contractor ICLO�I]P'B.GL3K� Address�_ �AjA7.E5'r' License No. '51�2�" zPhone r"} -134 TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER)-<, Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. }ReP-6f11I FJ FOUNDATION AGRICULTURE WELL OTHER WELL 44*&Ka1MP6r_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS .� ❑ Industrial ❑ Open Bottom G Manteca Die. o1 Well Excavation_ Ola. of WON Cesirq t CI DanuticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing__ Specifications PI Public Cl Other 11 Delta Depth of Grout Seat Type of Grout I I Irrigation _Approx. Depth I I Eaarrr; Surface Seal Insmllad by Repair Wwk Done ❑ Type of Pump H.P. Stats Work Dors_ Wall Destruction ❑ Well Diameter Selling Material i Depth Depth Filler Material G Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlAOOITION I I DESTRUCTION I I INo>�t} lad it public waver q availblj' �}� Installation will anus: Residence_ Commercial_ Other Number of living units: _ Number of bedrocims SAN J9� Character of soil to a depth of 3 feet: _�1113t o ail SEPTIC TANK ❑ Type/Mfg Capacity ONM .q�yl� PKG. TREATMENT PLT.❑ Mood of Distance to nearest: Well Foundation_ Ptopeny Lire LEACHING LINE ❑ No. 6 Length of lines _ Poral length/sire FILTER BED ❑ Distance to nearest: Well Foundation _ Property Line SEEPAGE PITS I I Depth _Sire Number. SUMPS Ll Distance to newest: Well Foundation Property Line , DISPOSAL PONDS ❑ 1 herby car ify that 1 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 Josgwn 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 arnploy any person in such manner as to becomb subject to workman's cornpansstion laws of California."Contrecto'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 pernicious subject to workmen's companies- tier,laws of Callturrnia:' The applicants must call for UI required inewtions. Complete drawing on reverse side. ,A Signed X Title: 15T,^ M1412"Moire- Date: _ 3 30 �7T FOR DEPARTMENT USE ONLY Application Accepted by Data Ph',or Grout Inspection by Date Final Inspection b Deaf. ' Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Ravironmental Health Permit/Services q. sl 445 N San Joaquin, P O Box 2009, Stkn, CA 9 O1 s 0 02� . <L FEE AMOUNT DUE AMOUNT REMITTED K RECEIVE By TE etw RMIT'NO. E EN.tau Baty.r r n a,, f 3QT i�a3 EN 1471 t l/