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APPLICATION FOR PE ILS_r. 00&oz SAN JOAQUIN COUNTY PUBLIC HE S— G ENVIRONMENTAL HEALTH D OI Y�p J 445 N SAN JOAQUIN, PHONE ( �68-342e P O BOX 2009, STOCKTON, fA95;,f l PERMIT EXPIRES 1 YEAR FROM EtI SUED `) (Complete in Tripli a Application in hereby made to flan Joaquin County for a Permit to construct and/or install the work herein described. This application in made in compliance vith Has Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services.I,, -�-///� a l Of5- rn Wy4�ll' City — Job Address �'„ D �1 11 r /�/l�1 �'�.�� /�/�L�ot ,S,ize/Acreage n -1 Owner's Name P Sy)� Address � rA 1 '1 S7-f L W.Q.tYic.X.(A.n'=i_o- _ Phone Contract Address C�6 / {License No ZS Z& Phone—SO TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 Bonom ❑ Manteca Dia. of Wall Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications fl Public n 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 U Type of Pump H.P. State Work Done _ („ Well Destruction ❑ Well Diameter Sealing Material i Depth DepthTiller Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I IREPAI ADDITIONK DESTRUCTION I I INo septic system permitted if public sewer is 1'n available within 200 Isar.) (.l Installation will servo: Residence v Commercial_ Other y Number of living units: -/— Number of&drooms Character of sa to a depth of 3 feet: zA^- 1J'C�JN� Water table depth SEPTIC TANK ❑ Type/Mfg O ./.1�A / Capacity No. Compartments ?� PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 1 ' LEACHING LINE 1;F(_No. 8 Length of lines T9tal length/size a f t FILTER BED ❑ Dictanca to nearest: Well�Q± Foundation /O t Property Lina S SEEPAGE PITS ril Depth y� dumber t SUMPS Distance to nearest: Well VX' 4- Foundation 10 R' Property Line + DISPOSAL PONDS ❑ 1 hereby cenity, 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 centiles the following: "I certify that in the performance of the work for which this permit is issued, I shafl not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: "I cenity that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion lava of California." The applicant at call quk d inspections. Complete drawing on reverse side (� Signed X-7 ti+'I Title: J Date: I I c 1 DEPARTMENT USE ONLY Application Accepted by Data / Area / Pit or Grout Inspection by Date Final Inspection by Data 40 r/ Additional Comments: �' v 36 "fed" is Applicant - Return all copies to: San Joaquin County Public Health Services Y/:...J\41_4/Q3 Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 1� INFO1AMOUNTTDMDUE AMOUNT REMIT-TED `CCAS, RECEIVED BY DATES PERMIT NO. M y _EN t} IaeV.Irael ✓ !� U EN u.at