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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 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. 4— Job Address ST City I r �li` Lot Size/Acreage Owner's Name IFAL �It QdO Address 3717 we57ereet 4, Jr* P A`5`Pftibn§ � Contractor&4&&.� ZAt!Y k etky— Address 5965 S?-14V g•S%0-s License No. OhU _Phone -sl6 TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT n DESTRUCTION O Out of Service Well Cl PUMP INSTALLATION V SYSTEM REPAIR O OTHER O Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing 7kDomestic/Private )KGravel Pack O Tracy Type of Casing =ye- Specifications M Public Cl Other O Delta Depth of Grout Type of GroutG Irfioation .�. Approx. Do th O Eastern Surface Soul Insta `�'t 14,11A Repair Work Done U Type of Pump H,P. I hie State Work Done _ Well Destruction O Well Diameter Sealing Material 4 Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION M DESTRUCTION 0 INo septic system permitted if public sewer is available within 200 lost.) 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 O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, Cl Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O I hereby certify that 1 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 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 t call for all uir inspgctions. Complete drawing on reverse side.�/ Signed Title: N Ir-a" /gym,- Date:61 ? b FO EPARTMENT USE ONLY Application Accepted by .-s Datares Pit Grout 10 pection by Datal� - �e/Final Inspection by Data 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 INFO AMOUNT DUE AMOUNT REMITTED CK #CASH RECEIVED BY DATE PERMIT'NO. 13 t f� t o� 7 A- Z-�r-p o 4 ° 3 . EH tU•24 INEV. i n sl EM;42e