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APPLICATION FOR PERMIT C� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES [ ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 pgUll EUIRES 1 .YEAR PCOM DATE LUMP (Complete in Triplicate) Application is hereby rlaade,to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in ccupliance with San Joaquin County Ordinance No. 549 and 1962 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address aV 14Sa..I W4 City Lot Size/Acreage Owner's Name FeW4 fJ "" &70 Address r Z E- G� w11 Phone IYLIV c-57 Contractor f'EC.�2r✓w. Address 2 M 4�rL, 57-0-5License No. �/ 2261? Phone I SS-J17/7- • ' TYPE OF WELL/PUMP: NEW WELL Q WELL REPLACEMENT 17 DESTRUCTION L1 Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ - OTHER CWL ` Monitoring Well L ing ll DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL�FLD.- PR LIC C FOUNDATION AGRICULTURE WELL OTHER WELL PITS3SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D Industrial © Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications- - M Public Other IC3 Delta - Depth of Grout Seal w --.Type of Grout., - �7�tNNr L- [J irrigation ^Approx, Depth d Eastern Surface Saul Installed by 4 Repair Work Done L] Type of Pump H.P. State Work Done_ Well Destruction O Well Diameter Sealing Material i Depth a Depth Filler Material i Depth ,/ Sor �� TYPE OF SEPTIC WORK: NEW INSTALLATION G REPAIR/ADDITION C1 DESTRUCTION G (No septic system permitted if public sewer is r available within 200 feet.1 f r installation will serve: Residence Commercial-_,,,_ Other r �j Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ` Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity_ No. Compartments PKG. TREATMENT PLT.C1 Method of Disposal r M Distance to nearest: Well Foundation Property Line t f I LEACHING LINE ❑ No. & Length of lines Tota! length/size FILTER BED n Distance to nearest: Well Foundation "' Property Line SEEPAGE PITS 11 Depth - Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 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 ridt 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 componsa ` tion laws of California." The applicant c,�II--ff7or all quired inspections, Complete drawing on reverse side. Signed C1• Title: AM. kiP629I,1 a Sef- Dole: 5 -7 --- FO DEPARTMENT USE ONLY Application Accepted by s Date Area Pit or Grout Inspection by Date Final Inspection by AAM Date Additional Comments: I Applicant - Return all copies to: ' PP p SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES f 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 85201 , FEE AMOUNT DUE AMOUNT REMITTED CK X X RECEIVED BY DATE PERMIT NO. INFO /��](/} r EH 13.24 IREV.s/KSS t.J4 l Q i./s� r EH:x•20 � ,�. ' � �