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APPLICATION FOR PERMIT a}U J SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOB 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT &MIRES 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 Services. Job Address A Z-14 A M® /LA City 5 7-kl J Lot Site/Acreage 2/0 k, 3 0 0 Owner's Name F- 6 D A/0 P ir1 A Ad Address Phone 3 ' 3 9 v Contractor FLl1//D E. /tfc'fcTd�Address 7 Al, AA,&Zd T � License No. �7'SD-'�G Phone `3 97 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION O Out of Service Well O PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER ❑ Monitoring Well O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS C1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS1:31 L/ fl Industrial O Open Bottom O Manteca Dia, of Well Excavation Dia. of Well Casing (J Domestic/Private O Gravel Pack O Tracy Type of Casing Specifications M Public Cl Other O Delta Depth of Grout Seal Type of Grout U Irrigation _ Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done L3 Type of Pump H.P. State Work Done_ Well Destruction O Well Diameter Sealing Material i Depth Depth Tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION DESTRUCTION G INo septic system permitted if public sewer is available within 200 feet.) Installation will sere: Residence Commercial— Other Number of living units: Number of bedrooms _ Character of soil to a depth of 3 feet: G !r A Y Water table depth SEPTIC TANK O Type/Mfg X I S 7-)AJ G Capacity No. Compartments PKG. TREATMENT PLT, C1 Method of Disposal Distance to nearest: Well Foundation Property Line }k LEACHING LINE 134-"No. iL Length of lines 7S Total length/size 7S FILTER BED ❑ Distance to nearest: Well Foundation 4.40 ` Property Line f SEEPAGE PITS Iq1 Depth LV Size 4_9 ` Number SUMPS LI Distance to nearest: Well 2:39M Foundation /00 Property Line DISPOSAL PONDS O 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 Son 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 applicant must call for all required inspections. Complete drawing onn�reverse side. Signed X � Title: Date: /2-- 14-%V 301RI DEPARTMENT USE ONLY / J, Application Accepted by Date /� /` v Area Pit or Grout Inspection by Date Final Inspection by Dateh- d Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. INFO [� /j� CASH . EN 11.21111EV.ii»el /�% /l 7 ly`iy fB Ftp- 3�� EN 11•m