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w APPLICATION FOR PERMIT k I SAN JOAQUIN COUNTY PUBLIC EEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 k (209) 468-3447 i R DATE ISSTTVnih (Complete in Triplicate) .i ,G Application is hereby made to San Joaquin County for a permit to construct and/or install the work bereinidescribed. This application is trade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. I Job Address ►� IC�!= City LotSize/AcreageI� Owner's Name Address r - Phone Contractor L�r�j�I1.LJ1�6 J'ldress C License No. 1�L Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Fl DESTRUCTION C] Out oto 5arvlce well Cl Y`PUMP_INSTALLATION ❑ *' SYSTEM-REPAIR L7 ,o;, o6 .LOTHERdX- 4F Storing Well �3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS rt INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F-1 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well iCasing E CJ Domestic/Private 0 Gravel Pack CJ Tracy Type of Casing Specifications M Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout [� j MI Ir6oation Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work.Done _ k Weft Destruction ❑ Well Diameter Sealing Material i Depth Depth Piller Material Z Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITION 0 DESTRUCTION G fNo septic system par to if ublic sewer is available within 200 f. ENT Installation will serve: Residence_--, Commercial_,..,. Other RECEIVED Number of living units: Number of bedrooms I�� 19910 , Character of soil to a depth of 3 feet: Water table depA I SEPTIC TANK ❑ Type/Mfg Capacity No. Compat #p PKG. TREATMENT PLT. ❑ Method ofti1 FE E)VIUS Distance to nearest: Well Foundation Property LineE2-IRaINMNTA L KALI f1 ayis!Dr r. LEACHING LINE ❑ No. 6 Length of lines Total length/.size t FILTER BED ❑ Distance to nearest: Well Foundation Property line i _ -SEEPAGE PITS,-_ 1.1 ."Depth_ Size, Number. SUMPS LI 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 ordinances, state laws, and rules and regulations of the San Joaquin County I� Home 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 shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring of sub-contracting signature certifies the followino:"I certify that in the performance of the work for which this permit is issued, I shall sinploy persons subject to(workman's compensa- tion laws of California." ! The appllcant tcall for all r uired in coons. Co fete drawing on reverse side. I Signed �Title. a&Dl.,A1 r _- Date: 44 I FOR DEPARTMENT USE ONLY i Application Accepted by 6441.4 Date Area t Pit or Grout Inspection by Date `Z Final inspection by Date Additional Comments; - h Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 85201 i i FEE INFO AMOUNT DUE AMOUNT AEMiTTED CASH RECEIVED BY DATE PERMO'NO. EH 13.24(REV,1 i n 5) �. .00 76c� .D 0 1n icg fH 34Z6 `'�4