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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEAL'T'H SE ICES ENVIRONMENTAL HEAI.,TII DIVISION 445 N SAN JOAQUIN, PRONE (209)46$- P O BOA 2009, STOCKTON CA 952 PERMIT EXPIRES I YEAR FROM DATE ISS[TED J 9 1190 (Complete in Triplicate) Appliestian is hereby made to Ban Joaquin County for n permit t.o construct. and/or inEtN�y' *N*� q�y Application It made in cafrgfliance with Ban .Tanquin County Orrlfnnnce No. 51r9 erred 1$62 and tfi� R � d1+ crlbed. This Joaquin County Public Health Services. $�rlatione of San Job Address .re/ ]�� Q ' Y Lnt Size/Acreage --�� Owner's Name Address E�tfhS�x End; A CJI �T,.�L 1 1f/=1_� Phone "3334 Contractor Address a ,. `�/� rRa�� o� �_.lV�'JS2C l.iEG_ �.t License No. Phon1l��gSL�SY TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMFNT f-1 N DESTRUCTION I� Out of Service We1I Cl DISv PJniC.. PUMP INSTALLATION ❑ 5Y57EM AEP R L�1 OTHE MonitoringrWell TANCE TO NEAREST: SEPTIC TANK SEWER LINES ��(� DISPOSAL FLP. PROP, UNE[S {-f C.7 FOUNDATION �ZWAGRICULTUAE WELL Ti18R WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 7 � fl Industrial C) Open Bvftom f7 Manteca Dia. 01 Wall Excavation — per Domestic/Private L} Gravel Pack [7 Tracy Type of Casing..._.____ Specifications FI Public 011ier IV Pelta Depth of Grout Seat I I hritfation -- Type of Grout 1 __ Approx. Depth I I Eastern Surface Seal installed by — Repair Work Done L1 Type of Pump _ It P Well Destruction -- -� State Work on Well Diameter�Ln._A_� Sealing Material & Depth Depth Filler Material i Depth �----`� tYrq 4F Ff}pflG WORK; NF;W INSTALLATION I i riF..r+AllilAt)DMON t I TJESiRIJCTION I I fN4 anprrr, oyafnm permllted 11 public Sewer is Installation will serve: ResidenceCommercial Other available within 200 fest.l _—_ Number of living units; Number of bedroom Character of soil to a depth of 3 feet: SEPTIC TANK � - ---------- ----Water table depth ❑ Type/Mfg __ Capacity_—. No. Compartments PKG. TREATMENT PLT. Cl �- Method of Disposal Distance to nearest: Well —_�__ Foundation Property Ling LEACHING LINE 0 No. $ Length of lines _ v Total langTh/size FILTER BED —_ f=i Distance 10 nearest: 1/ p{I _— Foundation .� Property Line SEEPAGE PITS 11 Depth — `— Number — SUMPS 1.1 Distance to nearest: ell --`e — DISPOSAL PONDS L7 Foundation Property Line I hereby certify that I have prepared this application and chat 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 10 workmen's compensation laws of California." Contractor's hiring or subcontracting signature cerlifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons tubiect to workman's compenza. lion lawn of California." The applicant must calf for all requi ed Ins Ctions. Complete drawing on reverse side. Signed X - ��"...." Title:4�eC,e —. Date: FOR DEPARTMENT USE ONLY Application Accepted by _ �Z 2 - -� - - ---�-- Data � Area J Pit or Grout Inspection by c Dale -- Final Inspection by _ Additional Comments: Date nhpl irn'nt. - 11 r.t:nrn nil seep{q9 Lv; Snn Jonquln County pub)lc IlerfT t:h Sof v.trr g Envlronmgntni fIr_rfil.h prt-Inst/Sorvicen o/gst� 5� 415 N Snn Joaquin, P 0 Aox 200P. Rtkn, (;A 95201 FEf AMOUNT DUE AMOUNT REMITTED CK INFO CASA RECEIVED BY DATE ----- - - PEAMIY'N0. I. Tr< IT.^r IREv ,psiks U� OO FIr Ia M (� ,Dn �_��.__ �013 � -z r -� 3�e �