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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �✓ ENVIRONMENTAL HEALTH DIVISION �E P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 RERMIT EXPIRES 1 YEAR PROM 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 Service ,.y, ^ / n /� Job Address (�7 67 al �C,4/4ey City 0000 Lot Size/Acreage elx Owner's Name 2&6: 1 "-paz'pAddress J Al*" Phone o o �;,�� ,,/,�� L > Contractor� y�C��.c�.f Address /'1Cj �� r� License Nc j3d'S hone ✓ y Y.? TYPE OF WELL/PUMP: NEW WELLW WELL REPLACEMENT ❑ DESTRUCTION O Put of Service Well O PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER O Monitoring Well [7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 6 ieomsstic/Private >Ia Gravel Pack O Tracy Type of Casing ,/� F-• PQ J" �� Specifications Y M Public Cl Other O Delta Depth of Grout Seal 106 Type of Grout «�r� G Irrigation Approx. Depth D Eastern Surface Seal Installed by Repair Work Done U Type of Pump Syjj9 H.P. 3 State Work Done_ 27 Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION CI DESTRUCTION CI (No septic system permitted if public sewer is Available within 200 feet.) Installation will 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE CI No. & Length of lines Total length/size FILTER BED CI Distance to nearest: Well Foundation Property Line ' SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O r 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, anckla 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 permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applica:;,;�rWr allquirad inspections. Complete drawing on reverse side. Signed X. `" Title: 6kAf?`- Date: FOR DEPARTMENT USE ONLY �7 / Application Accepted by Date Area Pito rout apection bye Date ��/� - 7 final Inspection !�✓I Datil( Additional Comments: l_� "A111W LL1rL4 / .26JDta.— Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESa5- ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED C / . RECEIVED BY �DA�T.E7 PERMIT NO. EH 1J•2�IREV.�in5� EH 11.2e C., ? w,e 75 30�F/ )0� /,