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APPLICATION .,t•.\ SAN JOAQUIN COUNTY PUBLIC HEALTH ENVIRONMENTAL, HEALTH AIVISI ✓ 445 N SAN JOAQUIN, PHONE (209)4( P O BOX 2009, STOCKTON, CA 9! G T1, Rffym UV_n Tnlco Y via AD VDI -NU nAMV (Complete in Triplicate) 3 - -�o TVV LID, I— Application is hereby made,to San Joequln County for a permit to construct and/or ins a wo application is made in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Putlic Health Services. j Q. / -� / / I a.t %i r-1, n:... T.nt. RI z IArrekae Jour,uuraaaY - .-.--....--+r'�.� - • - -- — Owner's N 7� !� Address i 7'l ¢—i--�---- -Phone lA 1-70 DATE17 C Contract » Adtlress - _ _ __ �_ � erase No 7i.�T Phone 'r TYPE OF WELLIPUMP NEW WELL 17 WELL REPLACEMENT (-' DESTRUCTION D Out of Service Well Cl PUMP INSTALLATION ❑ SYSTEM REPAIR C OTHER D Monitoring Well piSTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD._PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PAO_BLEM AREA CONSTRUCTION SPECIFICATIONS P. Industrial 0 Open Bottom CI Manteca Dia. of Well Excavation _ Dia. of Well Casing f.l Domestic] Private L1 Gravel Pack 0 Tracy Type of Casing_ ..__.___.. Specifications I'I Public 0 Other 11 Deltd Depth of Grout Seal Type of Grout I I Irrioation ___ ApMor. Depth 1 I Eastern S�rfaca Seal Installed by - - Repair Work Done C3 Type of Pump H.P ___ State Work Done Well Destruction 0 Well Diameter _ sealing Mat.erisl i Depth Depth Filler Material if Depth TYPE OF SEPTIC WORK, NEW INSTALLATION i I F1EPAIR/AD0IYI0N,^ DESTRUCTION I I INo septic system permitted if public sewer is available within 200 test.! lnsta4stion will serve: Residence 1- Commercial 4 Crfter Number of living units: -I.__ Number of bedrooms Character of soft to a depth of 3 toot: C Water table depth i SEPTIC TANK Type/Mfg Capacity %'� �'�lo. Compartments it PKG, TREATMENT PLT. O Method of Disposal t Distance to nearest: � ) Q1 Well IF s.p!*Oundation �" __ -- Property Line LEACHING LINEJE�4S4-U No. 6 Length of lines _ Imal length/size FILTER BED C1 Distance to nearest: Well _ Founoation _ Property Line SEEPAGE PITS 1 1 Depth -- Size � Number, _ SUMPS L' Distance to nearest: Well Foundation Prope►ty Lime 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 peiiormance of the work for which this permit is issued, t shall not employ any person in such manner as to become subject to workman's compensation laws of California." Conirector's hiring or sub -contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's Compensa- tion laws of Californls." The applican ST call farrill renurnaDectr no, COmple drawing on reverse side. Signed Title: Dater "► �. FOR DEPARTMENT USE ONLY Apdic+tion Accaoted by _ .1�� pate Area�� Pit or Grout IT"cuon by Date Final Inspection by 4 tC[l,GT1 Data J 3 Additional Comrrtenta: MIL •. r/ 4, t,( ISS i Lei 1 L WCL I JI f 114 4 (lGc r l lei AIL J,1, /Vi4, t • t4, aM-C! Y'jL_tt I Applicant - Return all copies to: San Joaquin County Public Health Services lt'Ua w Environmental Health Permit/Services N14'14 445 N San Jnaquin; P 0 Box 2009, Stkn, CA 95201 EH 13-24 NtEV. �!N5. EH 14.29 INFO AMOUNT DUE AMOUNT gEMITTED CAKH RECEIVED By DATE17