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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 EMIT UPIRBS 1 I 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 and Regulations of San Joaquin County Public Health Services._ r Job Address "7 L1,,2a d A — Ao P _ City Lot Site/Acreage GAG Owner's Name ��f '/�C Aa �o►t s Address 6 V_L2 / L=UR.fd�e Phone Contractor Lla Ile 14 D F>-, I x Address r°0, aQ-4-i1a- License No-c_229-331A Phonea&_47-2 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR M OTHER ❑ Monitoring Well ❑ 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 0 Industrial 0 Open Bottom 0 Manteca Dia, of Well Excavation Dia. of Well Casing U Domestic I Private ❑ Gravel Pack n Tracy Type of Casing Specifications M Public 1-1 Other D Delta Depth of Grout Seal Type of Grout CJ Irrigation __.Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction � Well Diameter �[� Sealing Material a, Depth k Depth 1pQ Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITION CI DESTRUCTION GI (No septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms M Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. a Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line ��✓✓✓ SEEPAGE PITS I I Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 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: "I certify that in the performance of the work for which this pefmit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant st call for all r uired inspections. Complete drawing on reverse si a. Sign 4 A,4 A Title: Date: A O TMElYT USE ONLY { Application Accepted by L'A �'l1 . uy� Date ?�t� �. Area 1 3 Pit or Grout inspection by Date Final Inspection by,�LVN-`3 lam 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATED PERMIT NO.