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APPLICATION FOR PERMIT �, B"�f/rk, SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES JJ1.� ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application In hereby made•to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in coupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health/S1e>rvii�ces. ,y Job Address 9767 �� /_L`/1 � City smc �y Lot Size/Acreage Owner's Name �� F� Address Z96 ,tat1LlLEQzlPhone 3 Contractor C4LgMW /iLddress j(�itense No. Phone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT _. DESTRUCTION O Out of Service Well 0 PUMP INSTALLATION O SYSTEM REPAIR O >�OTHER 0 Monitoring Well [1 DISTANCE TO NEAREST: SEPTIC TANK 1,(dCZ SEWER LINES DISPOSAL FLAZ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL ',r PITS/SUMPS t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C.7) Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing 1=6-Oomsstic/Private C*-Gravel Pack O r c Type of Casing I'Vc SL6>r. /l6 Specifications IO Public 1'l Other Depth of Grout Seal 1��` Type of Grouten&I-DRE G Irrigation -24V Approx, Depth O Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction � Well Diameter _7/AQ--,L Sealing Material & Depth Depth u� .� Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION C1 DESTRUCTION CI INo 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 toil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Q Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE O No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I 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 sub-contracting signature certifies the following: "I carts 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 appl' n Itc or requ' ins pe ns. Complete drawing on r se side e Signed Title: =� �`E� - Date: F TMENT USE ONLY f Application Accepted by ri A^ Date 1 4D1 R Area L� Pit or Grout Inspection by ill '�p Fin I In pection by Date Additional Comments: _ Applicant - Return all copse AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES � � sS ,A 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 IEEE AMOUNT DUE AMOUNT REMITTED CASH CK R�`E(CEIIVVED BY DATE PERMIT'N0. . EH 13•74 IIIEV.�ine1 �� ,9 EM 7 .20