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APPLICATION FOR PERMIT [wry r- SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �� (� ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 a� (209) 468-3447 \ YEAR PRQM PATE ISSUM (Complete in Triplicate) Application In hereby made,to San Joaquin County for a permit to construct end/or install the work herein described. This application is made in coarpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health ServiXCA Job Address 67 & / 'D — City ZJ,✓t Lot Site/Acreage 7' Owner's Name �PoZ - -- Address �A Phone f -6 0'0 r Contractor�'� _ S Address 1423 •✓;y 0 F License N hone y y� TYPE OF WELL/PUMP: NEW WELLW WELL REPLACEMENT n DESTRUCTION ❑ t of Service Well 0 PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER D Monitoring Well ❑ DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE ;L-- 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 %epomesticIPrivate >1a Gravel Pack n Tracy Type of Casing [/C Specifications M Public Cl Other ❑ Delta Depth of Grout Seal ,!'0 _ Type of Grout M Irrigation e v Approx. Depth 0 Eastern Surface Soul Installed by -1" Repair Work pone U Type of Pump Svc H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Tiller Material i Depth TYPE OF SEPTIC WORK; NEW INSTALLATION 0 REPAIR/ADDITION 0 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. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING UNE ❑ No. i Length of lines Total length/size FILTER BED 17 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Wait Foundation Property Line r DISPOSAL PONDS O I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and'ar rules and regulations of the San Joaquin County Home owner or licensed agent's signature cenifies 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 applicant must 111 11 1 r all r wired inspgctions, Complete drawing on reverse side. Signed )(_!i2r''^ Title: pate: FOR DEPARTMENT USE ONLY / �7 Application Accepted by Date[!( Arse d` , Pit o rout spection by yam/'/ Date(- {/'Z�7_0? Final Inspection by '' J✓1~ Additional Comments; «rG�_7'R' "�"'' � �Gi"+' � *� 2wo _ Applicant - Return all Copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES w` 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON. CA 85201 FEE INFO AMOUNT DUE AMOUNT REMITTED C ��7-R�-EE`CEIVED BY DATE PERMIT NO. . EH13-24fAEV.»N5i / (� tJ / C1-t1 1271 /rnvr'1� / /.'yw �11'- 4600 Wdi 70 3a 97 'po-V-