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4]`1-2654:561 P. 02 Wti 4 APPLICATION FOR r k"I T I , SAN JOARDIN COUNTY PUBLIC EL'EALTH SERVICES ENVIRONXENTAL E SALT$ DIVISION BOX 2009 T TON CA J5201 P O , S OCS , (208) 468-,8w PER]lIT g�RLr$__1— F(�fi rROM DA'TZ_-ISSUIII' (Complete in Triplicate) _ Apglicstlon in heraby 1440,to Sap oopquln County for a permit. to construct and/or instal] the vork heroin described. This application is malt in compliance with San Joaquin County Ordinance No. 549 and 1662 &ad the ales and ftegulationo of San Joaquin Count Puhllc Health Sery Cos. caR Y Job Address S �-- City Lot Size/Acreage Owner's Name G0C _ Add ss W.�QIt,EL Phone A �3 4994 Contractor 1 Addles �� OWC Lit case He. hone TYPE OF WELL/PVMP; NEW WELL C WELL REPLACEMENT [7r^ DE TRtf��TION Cr Out o Service Well PUMP INSTALLATION 0 SYSTEM REPAIR C1 `�� {�rl M� 'shoring well v DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP/LINE FOUNDATION -_ AGRICVLTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPIECIFiCATIONS 0 Industrial ,t 0 Open Bottom u Manteca Die. of Well Excavation Dia, of Well Casing L) Domestic/Private 0 Gravel Pack G Tracy Type of Caving Specifi6atians— O Public � j-- f-1 Other O Delta Depth Of GFout Seal ~ Type of Grout o� ('t�fK►f?ai- ci Irrigarion r _-Approx. Depth O Eastern Surfice Seat Installed ray in eer-S Repair Work Done 0 Type of Pump .____ ,__ H.P. ___ .. Slate Work Done —Well Destruction O Well Darne'lor ling t4aterial i Dorpth t Depth i Pillar Neterial i Depth - TYPE OF SEPTIC WORK: NEW INSTALLATION LI REPAIR/ADDITi0N 7 DESTRUCTION i=1 itNo septrc system permitted if public rvwer is available within 200 feet) Installation will serve: Residsnee Commercial_ Other Number of living units: Number of bedrooms __ t Character of soil to a depth of 3 Nov — - Water lobfe depth SEPTIC TANK. 0 Type/Mfg Capecity No. Companmenta PKQ. TREATMENT PLT.0 Method of Disposal Distance to nearest: Well - Foundation �� Property Line , AI CI ACHING LINE No, b Length of lines? Total len gth/sizeLTER BED 0 Distance to nearest: Well. Foundation Property Line £PAGE PITS it Depth Size Number } A LIMPS Ll Distance to nearest: Wall Foundation Property Line DISPOSAL PONDS 0 1 hereby certify that I have prepared This application and that the work will be done in acCofoanco with San Joaquin county ordinance!. state laws, and rules and regulations of the San Joaouln County i Home owner or licensed agent's signature certifies the following; "I certify that in the performance of the work for Which this perm+l is issued, I shall not employ any parson in such manner as to become subject to workman's compensation laws of California." Contractor's hiting or aub•conlraCting 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 oompenss- tlort laws of California." e applica ust cal all required int: p6ons, !Complete drawing on ever sidti- ignsdTitle: Date: FOR DEPARTMENT E ONLY Area Application Accepted by Date - Pit ar Grout Inspection tly Date.. Final Inspection by Date _........ Additional Comments: Applioe4t Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SSRYICHS ENVIRONMENTAL HEALTH DIVI610N PERMIT/SERVICVS 448 N SAN JOAQPIN, P G BOX 2009, STOCKTON. CA 95201 FEE AMOUNT DUE AMOUNT REWTTEO CASH RECErVEO BY DAtE E rt INFO - t'.M 19•T�trrCV. r��r • S _ J