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12.IZIC {- .%W APPLICATION %%.004 -ovray iiSAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES "e all n pq�yrftLLS t1 ENVIRONMENTAL HEALTH DIVISION _Lt1l.V2 fveL�S� raei {7r 445 N SAN JOAQUIN, PHONE (209)468-3420 Sub�Cf pmPyrt-y P O BOX 2009, STOCKTON, CA 95201 ZPg PERMIT EXPIRES 1 YEAR FROM DATE ISSIIID (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in Compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and,§egulations of San .. Joaquin County Public Health Services. Rpt✓- /.27o goo? Job Address /fa2%/Y /20 city.�;-'/0Ck10!V Lot Size/Acreage 9 Owner's Name //�` CM�NALO �3�19rtlD r I V'7, 7i Address / 8X/PV- Sr. ,! Ss� Phone E--2 w403 Contractor Address License No. Phone r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Cl 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 Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ` ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications a I'I Public II Other n 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_ t. Well Destruction ❑ Well Diameter Sealing Material i Depth / Depth Filler Material i Depth �p TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION X DESTRUCTION (No septic system permitted if public sewer is aIabIs within 200 feet.) �/ (a r Installation will serve: Residence_ Commercial_X_ Other�/_�G�Yr r��'• Bti� � /�'�'4 r r , Number of living units: _ Number of bedrooms - Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line k. LEACHING LINE )( No. i Length of lines � Total ength/size /ho C7 FILTER BED 'M Distance to nearest: Well OFT Foundation 9.3Property Line'. SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 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 persons subject to workman's compensa- tion laws of California." The applicant must call for all�required inspections.•Complete drawing on reverse side. R Signed X9�-sr li� W�. Title: )t5;U6i71/V1fE/� Date: _"VZ USE ONLY Application Accepted by Date 9 ��Area ` Pit or Grout Inspection by Date � Final Inspection by • 'S Date Additional Comments: ` Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 fEE AMOUNT DUE AMOUNT REMITTED CK if I RECEIVED BY DATE PERMIT NO. NF CASH sa EH EJ-24 111 W.v n el EH 1, ,6 l 1-