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-°� APPLICATION FGR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SESVICSS ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 f {209) 468-3447 P NIT XMIUS 1 YTAA FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application Is made in coupliance vlth Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulatioae of San t Joaquin Cotutty Public Health lees. r �C�tG:GS 5 �� j-�,inS/Ntt:.: 3+-}r'c:swf�rn /�I•^��, f' . Job Address aSScrn gd/�+tf.1f_ rh m rrrrc. �f'?t]r- City r6�"� Lot Site/Acreage �" _ 3 gee Noir., t°^rve Owner's Name ; y t3{ 1!G e y - Address y-V Phons -6'3e- Contractor CyP+'+tsT/i k0 L�etcSr�,'+CCS_Address S�eg Cil ��/� License No. �� 9'9_ Phone n & � TYPE OF WELL/PUMP: NEW WELL Ml-' WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE Cfee iYtp FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L71 Industrial ❑ Open Bottom ❑ Manteca . Dia. of Well Excavation ry Dia. of We"Casing rr�t �� arch 4G i.'C + U Domestic/Private Lyl`Gravel Pack VTracy Type of Casing Specifications C3 Public CI Other © Delta Depth of Grout Seal i 424kr kle Type of Grout ` CJ Irrigation .7-0 Approx. Depth fl Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump - - H.P. State Work Done Well Destruction ❑ Well Diameter sealing Material i Depth Depth Piller Material i Depth ' _4. TYPE OF SEPTIC WORK: NEWINSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION 0 INo septic system permitted if public sewer is A.,fit available within-2W fest./ y Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms 1 Character of son to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compenments PKG. TREATMENT PLT. C1 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines Total length/site ! FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS It Depth Sire Number, + SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS o = I hereby certify that I have prepared this application and that the work will be dons 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 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 parsons subject to workman's compensa- tion laws of California." The applicant"19st can for all reqs in irons. Complete drawing qn reverse she KKtarj iSf#'r � Signed Title: /� Doto: —IQ ' FOR DEPARTMENT USE ONLY Application Accepted by 11 } Date Area Pit Grow inspection by �Lf4 Bate Final Inspection by Date 4p-, T� i /Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 SOX 2009, STOCKTON, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEEVED By DATE PERMIT NO. . EH13-74IREV.i+K53 L1, ��