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APPLICATION 3 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 ' PERMIT EXPIRES 1 YEAR FROM 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. 11 XJob Address l�8yq Nu�k� A�A,Nti City\ d� Lot Size/Acreage � `Owner's Name DA, Paul Address Phone Contractor &UJA-`` =w1afioh Address \U-18, Cl�nl License No. S9(9(09 Phone 949-177`I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F1 DESTRUCTION O Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR 7$( .�5 OTHER O nitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER-LINES' DISPOSAL FL LIN FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f7 Domestic/Private ❑ Gravel Pack O Tracy Type of Casing_ Specifications I'1 Public Cl Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation __ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction O Well Diameter, Sealing Material i Depth n Depth Filler Material 0 Depth ver TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sower 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. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE O No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ' SEEPAGE PITS 11 Depth Size 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 subcontracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant ust call for I required inspections. Complete drawing on reverse side. Signed Title: -1 e S Date: S g3 FOR DEPARTMENT USE ONLY �1 Application Accepted by 7;_ JOQ <Z Z-4 C-A _ ! Date 7r��f�� Area t �— Pit or Grout Inspection by / Date .Final Inspection by �� t�ttG� 4ate Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, GA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 8 RECEIVED BY DATE PERMIT'N0. . EH 13.21(REV. ,11 00 �r�_� K r— I yL,5-L 3�0� EH t1•ZI C