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Y , t APPLICATION FOR PERIL I T -� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$--3420 P O BOX 2009, STOCKTON, CA 95201 b PERMIT E%PIRES 1 YEAR FROM DATE I S (Complete in Triplicate) Application is hereby tlrsde to San!Joaquin County for a permit to construct and/or install the vork herein described. This application is made in ccmpllance;with.Ban Joaquin County Ordinance No. 549 and 1862 and,the Rules and Regulations of San Joaquin County Public Health Services. 31 Job Address � "v � t r aNn t y City t Lot Size/Acreage /�Z Awv. Owner's Name �� Address Phone Contractor� �L- S Address ' ;r License No 7 �� Ph0ne.S�2'-1 TYPE Of WELL/PUMP: NEW WELL. WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR'❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK M� SEWER LINES DISPOSAL FLD.. PROP. LINE FOUNDATION ' AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS U) Industrial ❑ Open Bottom C) Manteca Dia. of Well Excavation Dia. of Well Casing N Domestic/Private Gravel Pack 0 Tracy Type of Casing_. i-'T,!� Specifications ^ V] Public Cl other Qn Delta Depth of Grout Seal _„_„ Type of Grout �l�\I �yrigation Ap ox Depth I i Eastern Surface Seal Installed by r r ` Repair Work Done 0 Type of Pump 1 H.P. State Work Done Well Destruction ❑ Well Diameter## Sealing Material & Depth Depth t Piller Material i Depth t TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I iNo septic system permitted if public sewer is �.. _ available:within 200 feet,I ' Installation will serve: 'Raaidenca-r `a%; Commercial_" Others Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance tornearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines Total length/size ` FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to ,neWest: Well Foundation Property,Lins DISPOSAL PONDS ❑ ! 1 hereby comity 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 Homs owner or licensed agent's signature oemifies 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."Contractor's hiring or subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I sholl employ persons subject to workman's compensa- tion laws of California." The applicant must call for alt roquWed in7ipections. Complete drawing on reverse ids. $� f f j Title: L i Date: DEPARTMENT USE ONLY Application Accepted by _ C :� rulkk& a iF4A4 eft Date Area QL Pit 04pnsllction by Date Final Inspection b Dat Additional Comments: _ - - Applicant - Return all copiew to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Rox 2009, Stkn, CA 95201 FEE INFO AMOUNT OVE ; AMOUNT REMITTED CASH RECEIVED SY DATE AERMIT'NO. . EH 13,24 i11EV-r/4 SI J r D 3 EH 14-m �J d'0 9 �v e� 00 �7 �--f 13