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s. APPLICATION FOR PERU[I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 3. P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 R rROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application Is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban Joaquin County Public Health Services. JJ'' Job Address /r �� rte_____ _._ City _ Lot Sire/Acreage 7664--72 V �� Cddress ,,G ><. - Phone Owner's Name ._..s-- � -- _ A7 Z,s Contractor. // `LC/�J ��$ Address — / &2&40ccense No.-Ov=Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR' OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS fl industrial ❑ Open Bottom C) Manteca Dia. of Well Excavation Dia. of Well Casing (� U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications V Public 1-1 Other ❑ Delta Depth of Grout Seat Typkof Grout C7 irriUation —Approk. Depth D Eastern Surface Seal Installed by s Repair Work Done Type of Pump H.P. Stat Work Done 'L Well Destruction ❑ Well Diameter Seating Material i Depth yf- i Depth Filler Material i Depthff ;Pt- TYPE OF SEPTIC WORK: NEW INSTALLATION O REPAIR/ADDITION 0 DESTRUCTION CI (No septic system permitted it public sewer is available within 200 foet.1 • 4 Installation will serve: Residence— Commercial_ Other Number of hiving units: Number of bedrooms Character of&oil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No, Compartments C <0 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. b Length of lines Total length/size FILTER BED C_1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby comity that I have prepared this application and that the work will be done in accordance with San Joaquin county Ordinance$, state laws,jand �% rules and regulations of the San Joaquin County Homo 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 shallemploy any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signa certifies the following: "l certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." �, n The applicaLrw or II re ns. Complete drawing on rev r •side. Signed Title: Date: - �1 FOR DEPARTMENT USE O Y ✓ f Application Accepted by Date ' Araa f Pit or Grout Inspection by Date f Final Inspection by Date / J I Additional Comments: ftAO j Q /� PEASA� ^ H •`� r Ct• �1 •et 8.11 p NONANENJOA -HENTPUOIVISIO008ERMIT/SEONi CA 85201 KciPS R r8 INFO AMOUNTTED' DUE' AMOUNT REMITCK CASH' RECEIVED BY GATE PERMIT'NO. + EH '2 IriEV.iiNs� /3'f� � A EH:3•I& rrr ti+ +tel O ~li+f