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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT LUIRE69 1 YEAR 9ROIC 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 1$62 and the Rules and Regulations of San Joaquin County Public Health Servic _ Job Address U l City Lot Size/Acreage Owner's Name Address �^�-�Y� Phone Contractor Address /�17L �3 License No.'5�LV6y Phone pa's^fir) 6 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well Gl PUMP INSTALLATION SYSTEM REPAIR OTHER 0 Monitoring Well [1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PtTS/SUMPS _ INTENDED USE TYPE OF WELL -PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack n Tracy Type of Casing Specifications `Public Ill Other ❑ Delta Depth of Grout Seal Type of Grout CJ Ifrioation 991L�� Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done /L —4-ype of Pump H.P. nu—e-- �_ _ State Work Done Well Destruction ❑ Wolf Diameter Sealing Material i Depth Depth Filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADOITION M DESTRUCTION M (No septic system permitted if public sewer is available within 200 feet.) Installation wilt 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 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT,0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. 8 Length of lines Total length/size FILTER BED F1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth "F Sire Number SUMPS Ll 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, an tt--, 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 no employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signatur 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 compens tion laws of California." The applicant must tail for pll required ins ctions. Complete drawing an reverse side. Signed XW'� Title ' --- Date: F R DE ARTMENT USE ONLY / Application Accepted by Date T / v Area_ it Pit or Grout Inspection by Date Final Inspection by Date 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 2008, STOCKTON, CA 85201 FEE CKIT - J INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY / DATE GfPEAMIT NO, . EH t3.24 IREV.trMsl /D�3 EH •7e r