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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION " 1 1601 R. HAZLLTON AVE. , PHONE (209)46$-3420 P 0 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 vork herein described. This application'is made in compliance with San Joaquin County Ordinance No. 549 and 1862 Lad the Rules and Regulations.of San Joaquin County Public Health Services. ' Job Address iNU) �+� � 1 DVL - -FJt'[(!.l ISD`14 1`�t�City � Lot Size/Acreage Owner's Name b P- Address IM S• E •. R• 9 Phone P_Wko on ?-$2S C3ISt r .tQ., Fs W4(-' S(2z1v$ �I 4.65 Contractor Jt\li� IV1 )�T Ili Address � t� OaA. 1A ak,-P alicense No. LZa__L � Phone 2 34J, - TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT C] DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERQ-- Monitoring Well ❑ 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 L] Industrial ❑ Open Bottom 0 Manteca Dia. of Excavation 711Dia. of Well Casing ❑ Domestic/Private 0 Gravel Pack .f Tlracy Type of Casing_ Specifications VI Public I i Other f1 Delta Depth of Grout Seai {S r Mil I I Irrigation Approx. Depth I I Eastern Surface Said Installed by WA Repair Work Dane ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth ou ' Depth Filler Material ri Depth HEALTH TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I (No septic syy��iit} }-tyml�rar is available mil dtll FAY Installation wA serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of$nil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments ` PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well Foundation property Line I LEACHING LINE ❑ No. b Length of lines Total length/size I FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS (l 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 Ccensed 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 applica call for ed inspections. Complete drawingonreverse side. rr f g ` l r ��• �` �}�- Signed Title c Date: (� • T FOR DEPARTMENT USE ONLY �J' r Application Accepted by Date - L Area Pit or Grout Inq atnion by Q BDate /12l� Z- Final Inspection by Date �z ` Additional Comments: l/ �`✓� Applicant - ftturn all copies to. Evan Joaquin County Public Health e D f Services, Environmental Health Permit/Services �� J II 1601 E. Hazelton Ave., P 0 Box 2009. Stockton, CA 95201 f�0 AMOUNT DUE AMOUNT REMITTED CASH CX V RECEIVED BY DATE PERMIT'NO. I . EH 13-24 IREV.Iin.S! + EH 31•�l4