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�+ - �CoCVU APPLICATION FOR PERMIT R # Otl/,?- SAN `rOAQUIN COUNTY PUBLIC HEALT jlirLES //c�Si� ENVIRONMENTAL HEALTH DIVISIQ6]r�1Uv ttFF 7 /O 445 N SAN JOAQUIN, PHONE (209)tjA8 ffii 01u0 _ P O BOX 2009, STOCKTON, CA g PERMIT EXPIRES 1 YE FROM DAT 5VC0 (Complete in Triplicate Application in hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application in made in compliance vlth San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Servic�es..a`''',, //'�� Cep Job Address //3/ I 4 6.nce '�"^ ' City Lot Size/Acreage VOS atAAd__' Q , /- Owner's NTT��addma 't"'t-!�+� Address � , >�� (' 956 S�Phone /-y7V/ !X) ContracteVt Va,� Address •Dc© 6,zK A2 License No7Z--I�'zz6 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Ll Out of Service Well ❑ _ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications 1'1 Public 11 Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Done Ll Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material A Depth Depth Filler Material a Depth N TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 1 I DESTRUCTION I Ileo septic system permitted it public sewer is �1W / available within 200 leat.l Installation will serve: Residence ✓ Commercial_ Other Number of living units: / Number ofJro_om Character of son to a depth of- fast: T Water table depth r SEPTIC TANK. )d Type/Mfg Capacity /SOU No. Compartments _ PKG. TREATMENT PLT. ❑ / Method of Disposal -fop Distance to nearest: Well f Foundation 6 Property Line %5- LEACHING LINE )R� No. d Length of lines Total length/size FILTER BED ❑ Distance to merest: Well '—�/�' Foundation C�'L_ Property Line i f SEEPAGE PITS 11 Depth Size Number _ SUMPS LI Distance to nearest: Well Foundation Property Lina 7C DISPOSAL PONDS ❑ 'n 1 hereby certify that I 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 Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this parent 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 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 applics at can to lar i d inspections. Complete drawing on rover" i X7 9 Signed Title: b� Date: 2/J �� /_3 FOR DEPARTMENT USE ONLY Application Accepted by Data Area Pe or Grout Inspection by Date Final Inspection by Data 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 ` UE INFO AMOUNT DAMOUNT REMITTED CA/SH RECEIVED ,(eAY�, /�DATE 9 PERMIT NO. IN FEE ,}].IaEV. �� V EM N-M