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' APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES'' `' y'�� ENVIRONMENTAL HEALTH DIVISION � ��A '4� k. ` F P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 J A N 2 5 ' � pMWIT Up RES 1-YEAR _PM DATE ISSU�UVt'RONIIA N AL HI-,�;;_I �4 (Complete in Triplicate) PERIM;T,/3rERV,'Ld, Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in c=Wliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. // Job AddressC224-55 r LL City Lot Size/Acreage T ,,ma�.�cc yrs) Owner's Name 1 rRat>Tess Phone r Contractor M s _-__1,1Z License No. hone !. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENTn DESTRUCTION ❑ Out of Service well Ll PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER O Monitoring well {� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL'S OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I �omestic/Private 0 Gravel Pack C3Tracy Type of Casing Specifications M Public la Other 0 Delta Depth of Grout Seal Type of Grout : M Irrigation —..Approx. Depth 0 Eastern dace Seal Installed by Repair Work Done {lY Type of Pump /�_ M•f. Stats Work Dona Well Destruction ❑ Well Diameter .—LIQ Sealing Material i Depth res Depth Filler Material i Depth _ Y E TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION Ll DESTRUCTION DI (No septic system permitted if public sewer is ` available within 200 Ieet.I Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ -Typo/Mfg Capacity No. Compartments PKG, TREATMENT PLT. 0 ¢ Method of Disposal Distance to nearest: Well - w Foundation Property Line LEACHING LINE C] No. fi Length of lines Total length/size FILTER BED n Distance to nearest: Well A v Foundation" Property Line { SEEPAGE PITS 11 Depth Size Number SUMPS _ L1. Distance to nearest: Well Foundation Property Line ' DjSP.OSAL_PON0S�_ 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 regulations of the San Joaquin County 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 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 workman's compensa- tion laws of California." The applic t t9st call to all wired 'nspe!ctions. Complete drawing on re se'side. k. Signed Title: Date: ! FO EPARTMENT USE ONLY . Application Accepted by Date Area ;Z/4Pit or Grout Inspection by Date Final Inspection by Date i g< Additional Comments; — Applicant — Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEE INFO AMOU,rNNTT DUE AMOUNT REMITTED CK I CASH � R�ECEEIVED BY /DATE PERMIT N0. . EH 13.24IREV.rinse / `' V/'� 4.flJ� Y Y 1 -� riM i�.la k