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• APPLICATION . SAN JOAQUIN COUNTY PUBLIC HEA TESRATVIRS ENVIRONMENTAL HEALTH DII I 445 N SAN JOAQUIN, PHONE (20 )Aw# P 0 BOX 2009, STOCKTON, i4TqV r4804 w EXPIRESPMIT Y d (Complete in Triplic Application is hereby made.to San Joaquin County for a permit to construct and/or ins work e 1crILISIR. TJ ma application is de in cocplia=e with San Joaquin County Ordinance Ho. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. � 57C.63 *-;7J6Cd41 fly .lob Address ")A/ :Z City Lot Size/Acretge SwP Gjjt.f; p S 7-e...i AV?? RA �Bz- - Owner's Name Address _ Phone Contraclot ft ''*A- �t» L-IM Ada a 3o�.��aavy � Zi"l�l-OU� License No. 6%"`I Phone TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT 17) DESTRUCTION O Out of Service Heil ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring well DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ar 0 industrisi ❑ Open Bottom G Manteca Dis. of Wail Excavation_ `V — Dim. of Well Caning f Cl Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casins 11�§LlOw S7,r0 Specifications Q I'I Public Cl Other f-i Oefte Depth of Grout Sea+ Or Type of Grout i I Irrigation rn Approx. Depth I I Easte Surface Seal Installed by 64en Repair Work Done 0 Type of Pump H,P_ _ State Work Done, Wall Destruction ❑ Well Diameter Sealing Material & Depth Depth Biller Material r Depth TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIWADDI'iION I I DESTRUCTION I I (No septic system permitted if public aawar is available within 200 feet.} Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms— t 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 to nearest: Well Foundation__ Property Line I LEACHING LINE ❑ No. 5 Length of lines — Total length/size FILTER BED ❑ Distance to nearest. Well Foundation _ Property Line SEEPAGE PITS 11 Depth Size Number, SUMPS Ll Distance to ne►.nat: Well Foundation Pro;-AM Lins DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joqiuin county ordinances, state laws, and rules and regulations of the San JOSQUin County Home owner or licensed epsm's eignalure certifies 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 workmen's compensation taws of California."Contrsctars Airing or sub-contracting signature certifies the following: "I wtify that in the performance of the work for which this permit is issued, I shall employ perso�ins subject to workmen's compensa- tion lawoj- ta" The appr►A�r u�msons. Complete drawing on reverse side, Signed /!3` Tide: G�� 6&b Lri 14� Date: _ FOR DEPARTMENT USE ONLY ApplicetkNr Accepted by Data fl'� ^� A g Pit or Grout Inspection by Date Final Ins pection Addidonsl Commants: Arpllcant,—'�Return all copies to: San Joaquin County Public Health Services (� Environmental Health Permit/Services a 4 445 N San Joaquin, P O Box 2009, Stkn, CAK /� tm PY INFO FEE AMOUNT DUE AMOUNT REMITTED CASH I RECEIVED BY ATE p1 RMlT' . FM 14•?.111EV.�isel I"14•M , D� ,3.q;% 11f 43 93 dll