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Y' APPLICATION 7� ,°"'« SAN JOAQUIN COUNTY PUBLIC HEALTH i &ENVIRONMENTAL HEALTH DIVIS Fl 445 N SAN JOAQUIN, PHONE (209)49 P O BOX 2009, STOCKTON, CA I FX # - -�--�-- i EXPIRES 1 XMA FROM TE I O (Complete in Triplicate) Application is hereby amide to San Joaquin County for a permit to construct and/or install the Work herein described. This application is wade in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. PW Job Address ,I AV __s City Lot Size/Acreage 5�a.0 w�;-R .lZ 3 0l Wt57 57{�ri+�T I `7! Owner's Name Address _ Phone /Ci�,a►�-7fG�/L /.�JG+�t:r.w P>yo rcw►-s DX much �'S7 49?3Soif Contractor Address License No.— Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ out of Service hell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ slattitoring Well 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 * Industrial ❑ Open Bottom G Manteca Dia, of Well Excavation_ 6--* — Die. of Well Casing `PVC Cl Domestic/Private ❑ Gravel Pack* El Tracy Type of Casing hill, A"5�" Specifications I'l Public 1 Otlpr fl Deh. Depth of Grout 5sa1 s Type of Grout I I Irrigation "' Approx. Depth I I Eastern, Surface Seni Installed by 6 ��e— Repair Work Done 0 Type of Pump H.P. —, State Work Dons _ Well Destruction ❑ Well Diameter ding Haterial i Depth Depth filler laaterial 4 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION r I REPAIRIADDITION I II I DESTRUCTION 111No septic system pa►miited if public.sewer is available within 2)a test.1 Installation will serve: Residence Commercial— Otlur Number of living units: Number of bedrooms 7� Character of soil to a dap it of 3 feet: Water table depth f SEPTIC TANK . ❑ Typo/Mfg Capacity "No. Comparmonts 0 PKG. TREATMENT PLT. 0 Method of Disposal ' Distance to nearest: Well Foundation_ Property Lirts dp7r/ �,649,6,,; LINE ❑ No. m Length of lines , Total length/size FILTER BED ❑ Distance to nearest: Well Foundation _ Property Line SEEPAGE PITS f I Depth Sire � Number. SUMPS LI Distance to nearest: Well Foundation ProMrty Line 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 npulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I Certify that in the performance of the work fa which this perms is issued, I ehall,nor OMPIOY any person in such manner as to become subject to workman'a compensation laws of California." Contractors hiring or sub-contracting signature certifies the following: "I certify Olet in the performance of the work for which this permit is issued, I shall employ persa-s subject to workmen's compensa- tion laws of Cal-Ifor in." The applicant f �9 r d inspections. Complete drawing on reverse side. / Signed 'd' Title- �'''+ � d'"WrY7 Dots: _! 1 9 FOR DEPARTMENT USE ONLY f Application Accented by &14Date _I % T3 A d�[� Pk or Grout Impaction by Data Final Inspection by Date Additlona►Comments: Applicants Return all copies to: San Joaquin County Public Health Services `(a Environmental Health Permit/6ervicee 454, z v D �I�� ,+1iV 448 N San Joaquin, P 0 Box 2009. Stkn, CA 95 1 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY ' E";itilaev.i?�a, ,� .W �x•�8' 357 V �P3 '0�11