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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH E VIRONYENTAL HEALTH DIVIS 445 N SAN JOAQUIN, PHONE (209)4 2� P O BOX 2009, STOCKTON, CA 11TT IRB (Complete in Triplicate INN# J�$ O r Application is hereby made to San Joaquin County for a permit to conatrul, aad/o 11�1■ 7 l �A`Th � application is made is compliance vith Ban Joaquin County Ordinance No. 549 and 1W and the Pules Joaquin County Putlic Health Services. 5« A77ACW--A Job Address " IV City Lot Size/Acrerge tl� �SD► ri!#S 57t►J Owner's Name' L"8i Address _ Phone ~ � /��tSo/vT��#t u►,v� l PAO J ws+ 1 PO -fa^"h +C&-7 Contractor Address License No._ Phone TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION ❑ Out of Service Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION �� AGRICULTURE WELL — OTHER WELt PITS/SUMPS INTENDED USE _T_YPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n� Cl Industrial ❑ Open Bottom Ci Manteca Dia, of Wait Excavation_ -!k Dis. of Well Caalrtg !'r' 171 DomesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing w�J f�. Specilicatimts I'l Public 1-1 Other 11 Delta Depth of Grout Seal s Type of Grout I I Irrigation ._.._Approx. Depth I 1 Eastern Surface Seel Installed by Repair Work Done L] Type of Pump H,p. State Work Done _ Well Destruction ❑ Well Diometer Sealing Material & Depth Depth Piller Material I Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADOI T IqN I I DESTRUCTION I I lNo septic system permitted if public sewer is available within 2W feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of aoil to a depth of 3 feet: _ Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.Cl Method of Dispose{ Distance to nearest: Well Foundation____ Property Line LEACHING LINE ❑ No, li Length of lines , Total length/size FILTER BED ❑ Distance to nearest; Wail Foundation _ Property Line SEEPAGE PITS if Depth Sizes Numbe►. SUMPS Ll Distance to ne►,rest: Well�� Foundation Property Line DISPOSAL PONDS ❑ I hereby corlify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stets twos, and rules and regulations of the San Joaquin county Noma owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to workmen's compensation laws of California." Contracto.s hiring or subcontracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ psraaris subject to workmen's compensa- tion Iowa of Calif in." The applicant r tad inspections. Complete drawing on reverse side. / f Signed i' Title: �f � b e--h Oar/S7 Date: FOR DEPARTMENT USE ONLY Appkatbn Accented by A .-)_... . Date Ph or Grout Inspection by pate Final Inspection Date Additional Conwnents: ! Applica - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/services 446 R Sao Joaquin, P O Box 2009, $ten, C 95201 11 r rF EE O AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By ►ERMI7'N0. i EN iisttiev.,.rrsl 0 .Vt .� cas; t