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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468--3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT _EXPIRES 1, YEAR FROM DATE_ ISSUED (Complete in Triplicate) Application is hereby made to Baa Joaquin County for a permit to construct and/or install the:vork herein described. This application is made in compliance with San Joaquin County Ordinance No. 5119 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address City Lot Size/Acreage ' a �i�-� J'2cr�- - ' Owner's Name �Gttt I P fAI � Ad ress n Phone ContractorICa� �/- l�'�/`a dress J`. �C t Il"P -- License No. s Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION Out of Service Well ❑ PUMP INSTALLATION 01 SYSTEM REPAIR ❑ OTHER❑ Monitoring Well ❑ _DISTANCE TO NEAREST:=SEP_YIC T4NK; _SEWER LINES, DISPOSAL PROP..LINE FOUNDATION AGRICULTURE'WELL OTHER WELL ' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION-SPECIFICAT SI(-, rf/ ^HCl dustrial ❑ 0 n Bottom ❑ Manteca Dia. of Well Excavatio Dia. of Wait Casin pI Qomestic/Private ravel Pack Y �[acy Type of Casing_ Piz Specifications v to I l Public rl 01`;11 ✓C-1 Delta Depth of Grout Seal �� Type of Grout f c I I IrrigaWn pprox.'Depth I I Eastern Surface Seal Installed by [/ Repair Work Done U Type of Pump H.P. s State Work Done_ Well Destruction )< Well Diameter _ Sealing Material i lkpth _ _ Depth 0 Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is .3 available within 200 feet.) Installation will serve: Residence° Commercial— Other Number of living units: Number of bedrooms N. Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines Total length/size L FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number ...�.� _ . -- � � �'5UMP5 �I`Diiitance to nearest: Well Foundatfan'� Property Lins �` 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 rubs and regulations of the San Joaquin County Home owner or licensed agent's signaturs oanifies the following: "I-certify that in the performance of the work for which this permit is issued, I shall not 'k employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workmen's compensa- tion laws of California." The applicant 01.0 req Lifinspeptions. Complete drawing on rovIt)lie side. Signed �/ Title: Date: T `tom _., ORMENT USE ONLY �j Application Accepted byZDate �J Area 0_ 2 L +1•.r_ A Pit rout pection by Date Final Inspectio by DateI Zal, Additional Comments: c3/. E�✓}�.4c �� ,Sl/ Applicant —Return all copibe to: San Joaquin County Public Health Services Environmental Health Permit/Services if 445 H San Joaquin, P 0 Box 2009, Stkn; CA 95201 ,I INFOFEE SH AMOUNT DUE AMOUNT REMITTED ` RECEIVED Y DATE PERMITNO. a £H 1124I8EV.1/l151 ,`^1� r Q IV?- / &(W 'T w EN 14.78 �}