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APPLICATION �4 ' SAN JOAQUIN COUNTY PUBLIC HEALT Lim ENVIRONMENTAL HEALTH DIVI {� ��00 445 N SAN JOAQUIN, PHONE (209 #2 P O BOX 2009, STOCKTON, CA u PERMIT EXPIRES 1 YEAR FROM DA E f/ q��' (Complete in Triplicat ) — Application is hereby made to San Joaquin County for a permit to construct end/or install the work herein descr ioed application is made in compliance with Sm Joaquin County Ordinance No. 549 and 1062 and the Rules and Regulations of San Joaquin County Public Health Services. 32 0 pA- IYD City �L— '� Lot Size/Acreage Job Address ..f" Owner's Name / Address _� � � Phone '�c Contra r Adtlre .ice License /chi Piton TYPE OF WELL/PUMP: NEW WELL ❑ of Service well D WELL REPLACEMENT ❑r DESTRUCTION ❑ Out Monitoring Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Ei' OTHER ❑ 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 ❑ Bottom ❑ Manteca Dia. of Well Excavation Open Die. of Well Casing CLD�tie/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications lq Public 1-1 Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation /_Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done Jd� Type of Pump - - H.P./yam - State Work one Ill Sealing Material i Depth W Well Destruction ❑ Well Diameter W Depth Filler Material A Depth TYPE OF SEPTIC WORK: NEW ILATION I I REPAIR/ADDITION I I DESTRUCTION I I (No"laiclable system ithin m permitted if public sower is avaNSTAL ., 0 Installation will serve: Residence— Commercial_ Other Number of living units: _ Number of bedrooms Character of wR to a depth of 3 fest: Vy�pyy�7�tt/eEIr table depth SEPTIC TANK ❑ Type/Mfg Capacity RoKOiArtr .� PKG. TREATMENT PLT. ❑ _ W Distance to nearest: Well Foundation Prop"/x''11 LEACHING LINE ❑ No. 6 Length of lines Totalj9�rl®[t1�alFILTER BED ❑ Distance to nearest: Well Foundation ENyIR 0� SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Lim DISPOSAL PONDS ❑ 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state lews, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature canities 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." Contractors hiring or subcontracting signature unifies the following: "I certify 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 /maty/f/-y all required ins , tions. Compete drawing on niverse side. Signed X -t pi � Title: �ff,'A9� Date: FOR DEPARTMENT USE ONLY 7�L Application Accepted by C - Date_LhL�.i-`— Pit or Grout Inspection by Date Final Inspection by �M AAkw Date s`2-42 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEEAM LINT DUE AMOUNT REMITTED C RECEIVED BY OAT PERMIT NO. INFO • EN 177x IREV.1/nal EM 14a1 V -