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V + APPLICATION FOR PERMIT I IN COUNTY PUBLIC REALTH SERYES JOA SAN ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCg'FON, CA 95201 (209) 4683447 � l YR (Complete in Triplicate) vork in Application is hereby made to San Joaquin CJooaquinaCounty OrdinancenNo. 549aando1862aand the eRules aadeRegulations ds of San application is made in compliance vith Ban 4 Joaquin County Public Health services. S� $TOL`KTaI./ f 0 0 E}�5T �Q.E_t o AJ City Lot size/Acreage i Job Address L)FST I ' �VF_— CAL, F3c.vM?1A6F_ Address Z�. rj'CDAI� (�L 11,E, SAPhone 7�6- 3�Z-dboo Owrtai s Name J(LfJF><MEQ zBz5 ice•. MVCrLA-!;1• License NoCS�aPhonex `'�b5� ILl Contractor Loro ddress WELL REFLACEMENT ❑ DESTRUGTkON Cl Out of Service Well Gl . TYPE OF WELLIPUMP: NEW WELL ❑ OTHEg �/ monitoring Well L7 SOIL �pyZ 1a1ic� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ !'"� 'f �0 SEWER LINES "F 5O - DISPOSAL FLDI 5V PROP. LINE D{STANCE TO NEAREST: SEPTIC TANK ti� AGRICULTURE WELL 5o OTHER WELL 1$ PITS/SUMPS 75 04, FOUNDATION I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , n Industrial ❑ Open Bottom © Dia. of Well Casing, Manteca Dia. of;Well Excavation .I U Domestic/Private ❑ Grave! Pack 13 Tracy Type of Casing Specifications M Public Il Other ❑ Delta Depth of Grout Seal Type of Grout G Ifrigation Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Vyork Done Sealing Material i Depth SAMD r—&r4JEW1: t 9WT- rtfNlw>Lrq 47,o Well Destruction O Wel! Diameter 1�BOY $�f.1T4Ai17� T Ht icoL so`` Depth Filler Material i Depth 14M TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 OESTRUCTION El INo septic system permitted if public sewer is available within 200 fest.) i t Installation will serve: Residence_ Commercial____ Other 4 r Number of living units: Number of bedrooms Character of soil to it depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg 'Capacity No. Compartments i E` PKG. TREATMENT PLT. C! Method of Disposal tl Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines Total length/size PAYMENT FILTER BED C;l Distance to nearest: Well Foundation Property Lin I ` 'I SEEPAGE PITS 11 Depth Size Number !s� SUMPS Ll Distance to nearest: Well Foundation PropertS. aUNTY DISPOSAL PONDS ❑ PUBLIC HEAT ,�PVJCFS I hereby certify that I have prepared this application and that the work will be clone in accordance wit 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." Co ra g signature certifies the following: "I certify that in the performance of the work for which this permit is issued, l shail amp a r s compensa- tion laws of California." The applics t lu l call for allr ad insWtiions, Complete drawing on reverse side. A. / Signed r�-�� - / /'� � °�� Title: � � `t Date: �� 3 JZJt FOR DEPARTMENT USE ONLY Application Accepted by II _ Date Ares Pit or Grout Inspection by 1 ate 7i� Final Inspection by �� Date` v Additional Comments: Applicant - Return all copies to: SAN JOA UIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES Z�t6ro 41.4,�_;r 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 85201 ! III IFEE NFO AMOUNT DUE AMOUNT AEMITTEO C SH CVVED BY DATE PJ RMIT'NO. • EH 13.24 IAEV.1/w%l Sq.� •� d�3 f `J ' al C� n ar�`R*., �';.�r•stii ,�-' - "�.ti _,.. _dY f:•< �..a..Ll_. 1 ` -