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Y APPLICATION FOR PERMIT 407` e7= ,E?�5Ga'2_ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PP-1,74- 72 �97Z P O BOX 2009, STOCKTON, CA 95201 J]G � - (209) 468-3447 Y (Complete in Triplicate) 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 compliance.vith San Joaquin County Ordinance No, 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address ZtL City , aLot Siz Acreage Owner's Name //J0 L'ALIA6A//Nd Address 5.4 W—eF Phone- Contractor 16s: J Address �� =�� License No. _l Z7Z Phone 4 44`-'9' TYPE OF WELL/PUMP: _ NEW WELL ❑ _ WELL REPLACEMENT 1-1DESTRUCTION ❑ Out of Service Well Gl PUMP INSTALLATION ❑ � SYSTEM REPAIR.❑ OTHER C1 Monitoring Well t� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES-,4 DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL ° ` OTHER WELL PITSISUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r M Industrial ❑ Open Bottom ❑ Manteca Dia. of Weil Excaoation""� -Well-Casing i *� '� Specifications U Domestic/Private 0 Gravel Pack " ❑ Tracy TYPa of Casing _ M Public 1-1 Other 0 Delta Depth of Grout Seal "--Type of Grout Ci Irrigation _ ..Approx. Depth 0 Eastern Surface Seal Installed by i Repair Work Done 0 Type of Pump Ft.P. State Work Done w~ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK:' NEW�INSTALLATIO REPAIR/ADDITION ❑ DESTRUCTtON CI (No septic system permitted if public sewer is available within 200 feet.) ; A Installation will serve: Residence� Commercial Other Number of living units: _L Number of bedrooms �- a.a Character of sail to a depth of 3 fest: C L Water table depth� SEPTIC TANK. - M"�Type/Mfg Capacity No. Compartments Z PKG. TREATMENT PLT. ❑ Method of Disposal 4 } Distance to nearest: Well Foundation Property Line Y - LEACHING LINELN/No. & Length of lineslength/size r Total len th swiz e �d FILTER BED 0 Distance to nearest; Well Foundation Property Line SEEPAGE PITS 14'-Depth Z_' Sire Number Y SUMPS 0 Distance to nearest: Well ./9Ie9> Foundation Property Line DISPOSAL PONDS 0 I hereby certify that ! 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: "1 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 applicant must call for all required inspections, Complete drawing on reverse side'. i Signed Title: Date: 1 Z ,Z4 9p FOR DEPARTMENT USE ONLY e, Application Accepted by Date ``® Area + Pit or Grout Inspection by Date Final Inspection by Date v" / I Additional Comments: — Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 448 N SAN JOAQUIN, P O BOX 2009, STUCKTON, CA 95201 ti( i FEfrf INFO AMOt1NT OtlE AMpt1N71tEMITTED CASH RECEIVED BY GATE PERMlT'NO. . FH 17-24IREV.l/NW \�� C1t� ,� Qt� Q `t ,� �,- ��U EH-26 4