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SAN .%I, IAQUIN COUNTY PUBLIC HEALTH JItVICES • ENVIBONYENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468 -3420 P 0 BOX 2009, STOCKTTON, CA 95201 (Complete in Triplicate) Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This eppllcat o is made in costpliawe with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health $ervices. r X32, 1��3';'W�r' 1 a hk Z City bot Size/Acreage Job Address . TM ^ 5%h RRtMLxa CN IOS' Owners Name W S NVAddress Zj-�( M i$St St' r Phone 5m Contractor Address 2S-2r8 E'LAJ-,� f Stb4— ,ense No.SIZ2108 (20 IT Phone *71 TYPE OF WELL/PUMP: NEW WELL JK WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well Atr DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -106' DISPOSAL FLD. PROP. LINE FOUNDATION O AGRICULTURE WELL OTHER WELL 20" PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUC'UON SPECIFICATIONS at C'1 Industrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wall Casing r.1 Domestic/Private X Gravel Pack n Tracy Type of Casing& � 40 Specifications i'1 Public t _ Cl Other n Delta Depth of Grout Seitl !O __ __ Type of Grout I I Irrigation i(MBrlt�er+ Approx. Depth )d Eastern Surface Seal installed by . Repair Work Done 0 Type of Pump H.P. State Work Done, WON Destruction ❑ Well Diameter Sealing Material A Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I Mo septic system permitted if public sewer is available within 200 feet.) Installation wig sow. Residence........ Commercial— Other Number of living writs: Number of bedrooms Character of will to a depth of 3 feet: Water table depth SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O ` I hereby certify that 1 haw 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 Acsnssd agent'*signature certifies the following: "I certify that in the performance of the work for which this permit is issued. I shall not employ any prnon in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature Cardfiu 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 compsnss- tion lawn of CaMomis." The appk*M must call f I inspections. Complete drawing on reverse side.. Signed Title: 16►� Anoa;Jre �1I Date: ll o 3�—__FOR DEPARTMENT USE ONLY �} Appticstion Accepted by Dat Ana +� ' �`-' Ph or Grout Inspection by ate Final Inspection by Date Addldo"Comments !f Applicant - Return all copies to: San Joaquin County public Health Services Environmental Health permit/Services 445 N Ban Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO1721 �j� )