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APPLICATION &MWAtq PUMP SMMOAN JOAQUIN COUNTY PUBLIC HEALTH P.O. Box 602 • Lindon, CA 9523E ENVIRONMENTAL HEALTH DIVISI04 h �.f. Phone (209) 944-5969 445 N SAN JOAQUIN, PHONE (209)46 1$I4a[ii State Lia p 521638 P O BOX 2009, STOCKTON, CA 95 Ql C # 0.tV PERMIT EXPIRES 1 YEAR FROM DATE SSU ' (Complete in Triplicate) Application 1e hereby made to Ban Joaquin County for a permit to construct and/or install the work herein dcscrlbed. This application Is made in compliance with San Joaquin County Ordinance Ro. 549 and 1662 end the Rules and Regulations of San Joaquin County Public Health>Jji �^ / qs�/��,„,'().�_��,., Job Address �ee IL '� C� YI[_� City 0C'r`r0 a- Lot Size/Acreage It /tk-eeMz Owne�■ Name0 V `9w'• r •1 Address gayit< Phone Contractor F& StWl ddress' 0&,4,j:%2- -4f A License No. Phone TYPE OF WELL/PUM : NEW WELL O WELL REPLACEMENT n DESTRUCTION O Out of Service Well ❑ PUMP INSTALLATION<`,x! SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS to Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ � Dia. of Well Casing ck F-1e 3Z Domestic/Private ;XGravel PaTracy Type of Casing T v... OL 16-0 Specifications I'I Public ❑Other n Delta Depth of Grout Seal f T pe of Grout "f I I Irrigation _.Approx. Depth �'��l I Eastern S dace Seol tnstalied by Repair Work Done ❑ Type of Pump 3:� H.P. 2 State Work Done _ Well Destruction O Well Diameter Sealing Na� Depth Depth Filler Material s, Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDIT'ON I I DESTRUCTION I I INo septic system permitted it public sewer b available within 200 feet.] Installation will sews: Residence_ Commercial_ Other _ F Number of living units: _ Number of bedrooms Character of soa to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capaciry No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Wel _ Foundation_ Propeny Line WENT LEACHING LINE ❑ No. g Length of lines _ Tctal long IM FILTER BED ❑ Distance to nearest: Well Foundation _ Pro I IVED 5 1994 f SEEPAGE PITS 11 Depth _Si:e Num SUMPS LI Distance to nearest: Well Foundation PI 4SERw-B DISPOSAL PONDS ❑ ENVIRONMENTAL HEALTH DIVISIO' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stela Laws, and runts and regulations of the San Joaquin County Home owner or licensed agent's Signature certifies the following: "1 cartify 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 compan"tlon laws of California."Contractors hiring or sub�comracNng signature certifies the following: "I certify that in the perlotmance of the work for which thls permit is issued, I shall employ persona subject to workman's compenu tion laws of C ilOrnia." The applicant at call for al qui, insp. tions:Complete drawings reverse aides.. Signed 4, Title:l� !9 Jn'(.11y�''1 Data: / FOR DEPARTMENT USE ONLY. (q��y.�c—�_/./-�(7,'�� Application Accepted by Date Area L{ / Ph o ou IrepeUbn by Date . .Final Inspection by 'r^" Dan Additional Comments; — 11 ��ApplicantAet �'7� pi - San Joaquin County public Health Services (qy� 0 ' —� ZfO03,�� Environmental San Joaquin, R Permit/Services Box 200Stkn, CA 95 6�� 3� I��`+ � INFO AMOUNT DUE AMOUNT REMITTEDC H RECEIVED BY DATE PERMIT'N0. Z13 O S 9 �QeM �1 IQAAAI.A t`) 4>LL 33?1�:�scf1 . fa ti-].ISEv.rtes]