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f APPLICATION FOR PERHIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 N PERMIT- EXPIRES 1 YEAR FROM DATE ISSUED (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 with San Joaquin County Ordinance No. 549 and 1862 and the Rules sad Regulations of San Jo uta Counnty Public Health Services. City ss S�— Job Address 4 2 e Lot Size,/Acre e /� X_I ;I . , f3(e .SaL a—Me Phone { Owner's Name C- f' Address / // ki Contractor A � i rleef 11'L Address Su F LSe Ira., v"LiC�e No.6a 62 b_� TYPE OF WELL/PUMP: NE WELL ❑ ELL REPL CEMENT L7 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER" Ngitoo in wet DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROt. LINE J FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wall Casing tik [1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_. Specifications l'1 Public 1-1 Other Fl Delta Depth of Grout Seal 5�_r Type of Grout Cj=J-v'Le-J-,+ _. i I 1 Irrigation -_--Approx. Depth I l Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Wall Destruction ❑ Well Diameter Sealing Material i Depth j Depth Piller Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION l I (No septic system permitted if public sewer is , available within 200 feet.) 1 h Installation will save: Residence— Commercial___,^ Other W Number of Inring units: Number of bedrooms Character of sod to a depth of 3 feet: Water table depth j 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 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number l SUMPS LI Distance to nearest: Well Foundation Property Line + DISPOSAL PONDS 0 I hereby cattily that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and t rules and reguiations of the San Joaquin County Home owner or licensed agent's signature Certifies the following: "I certify that in the performance of the work tot which this permit is issued, I shall not I employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hifing 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 Californ The applic must all or all inspections. Complete drawin on r v ne side. Signed Title:: Data: FOR DEPARTMENT USE ONLY Application Accepted by Date &-36. Z Areayn t�'4 Pit or Grout Inspection by Data Final Inspection by Date 10'T. Additional Comments: -U.- � r V-L' Applicant - Return all copies to: San Joaquin County Public Health Services 1 Environmental Health Permit/Services 445 N Sao Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMiT'NO. INFO CASH /1� ��t IqEM I124 KIEV. it ai �� CC) EDI®(a {�►/l'//' �G.3Q,9Z2+ L��D EN 14.10 Y� /�( /' I