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APPLICATION FOR PERMIT _ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES _ ENVIRONMENTAL HEALTH DIVISION P-liO BOX 2009, STOCKTON, CA 95201 (209) 468-3447 ESPIRES 1 YEAR I�ROId DATE_ ISSU�3 i 1��6� , ��= P (Complete is Triplicate) . Application is hereby made to Ban Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Heat ervices. _L AC 5,,[.a'7 4f k- G 1,l�� S Job Address 8 S -Elf `4 �� City f ` ' -- Lot Size/Acreage Owner's Name `-'Zo^ f✓AA r3 b { Address SA 6 - __ Phoney6's� 1 ' • Contractor �rt`'( ��ss Address� a� �/� License No.3773�r Phone33Y� TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION ❑,put of Service titch Cl PUMP INSTALLATION �1< SYSTEM REPAIR C] OTHER 0 Monitoring Well C7 1 " } DISTANCE TO NEAREST:•SEPTIC TANK SEWER LINES DISPOSAL FLD. . PROP. LINE. - FOUNDATION AGRICULTURE WELL s OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS d M industrial ❑ Open Bottom Cl Manteca Die. of Well Excavation_ Z"L Dia. of Well Casing DomasticlPrivate Gravel Pack0 Tracy Type of Casing, pYG Specifications C3 Public i l Other © Delta Depth o} Grout Seal S A Type of Grout M Irrigation Approx. Depth ❑ Eastern Surface Seal Installed byJ Repair Work Done U Type of Pump H.P. 3 State Work Dona ' - ..-- Well Destruction ❑ Well Diamete � `L Sealing Material i Depth --14 I!, - Depth Filler Material & ,Depth - I`1 TYPE OF SEPTIC WORK: NEW INSTALLATION 0_REPAIR/ADDITION Cl DESTRUCTION CI (No septic system permitted if public sewer is available within 200 leet.i " t Installation will serve:- Residence _ Commercial r _i Other E --�- Number of living unite: Number of bedrooms t ~ Character of soil to a depth of 3 feet: Water table depth v SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT=::Cl } Method of Disposal .�`; ( Distance to nearest: Well Foundation. Property Line I LEACHING UNE C1 No. 6 Length"-of-limos Total length/size FILTER 8ED'- fa Distance to nearest: Well Foundation Property Line r ".1 SEEPAGE PITS 11 Depth Sre tr Number i I 'SUMPS Ll Distance to nearest: We,,,-,- Foundation.'- Property Line DISPOSAL PONDS 0 _ ! I hereby certify that I have prepared this application and that the worts wi$l be done in accordance with San Joaquin county ordinances, state laws, an rules and regulations of the San Joaquin County k Home owner or licensed agent's signature canities the following: "I certify that in the-performance of the work for which this permit is issued, l 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 pirmit is issued, I shall employ persons subject to workman's compansa-. tion laws of California." 4 The applicant must c ll for all req 'rod inspections. Complete drawing on reverse sided Signedpe Title: Date: t FOR DEP RTMENT USE ONLY Applicat n Accepted by _ _Date_ .C�_ Area Pit or Gr u Inspection by Date Fina! Inspection by Q-419 DataLZr � Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERXIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 85201 FEE AMOUNT DUE AMOUNT FREM3TTED CK RECEIVED BY DATEPERM17'NO. INFO CASH rFs C1 0; Tb. _ • EH 13.24IREV. /A 5) f '4 LQO "`i+�� r Cto -3-3L-0 F'