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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 R ?ROM DATE 155UED (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 c=Wliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban Joaquin County Public Health Services. Job Address �`�'1.� _ citv%R441Aorgf0yL> Lot Size/Acreage Owner's Name w 4-c Address �LI�►�� Phone Contracinr G c+l .. LSt "tiflGG. AddressiPll-�71x 41� rs'vri.�rte+ License No. AS9eg11 ' Ptiohe a-;-2-u'L� 8 TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well [1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ElTracy Type of Casing Specifications M Public Cl Other 7 ❑ Delta Depth of Grout Seal Type of Grout M Irrigation —Approx, Depth ❑ Eastern Surface Seal Installed by Repair Work Dons. Ll Type of Pump.. ._. H.P. State Work Done Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIRIADOITION . DESTRUCTION G (No septic system permitted if public sewer is Cl� available within 200 feet.] Installation will serve: •Rssidence?!L Commercial— Other Number of living unite w-=I— Number of bedrooms Character of soil to s depth of 3 feet. Water table depth SEPTIC TANK 10 Type/MfgCapacity o. Compartments PKG. TREATMENT PLT, 0 y. � ��- `'1� - - Method of Disposal 'v Distance to nearest: Well Foundation Property Line LEACHING LINE , No. &-Length of lines Total length/size FILTER BED 'C] Distance to nearest: Well 61 Foundation el:)'( Property Line Ze r SEEPAGE PITS Jr Depth Jti Size Number SUMPS ;LI Distance to nebrest: Well Foundation l� ' Property Line /d' DISPOSAL PONDS ❑ 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 agint's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, t 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 permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all req u ins ctions, Complete drawing on reverse side. r SignedTitle: �° Date: _Lal& - - -- .- F DEPARTMENT USE ONLY -2 Application Accepted by Dat. Area ^� Pit or Grout Inspection by Date Final Inspection by 3 Y �-j0 �. Date �U Additional Comments 3 Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOJ[ 2009, STOCKTON, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH K It RECEIVED BY / DrAA.TEy}/q/ PERMIT'NO. . EN 13-14 InEv.�,n 5) , /o-d f V EM 74-20 JJ! !!!