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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 4 ' ENVIRONMENTAL HEALTH DIVISION f P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 R R (Complete in Triplicate) / Application is hereby made to San Joaquin County for a permit to construct end/or install the ,02vor--030 —cOin ribed. This O ' application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Reaulations of San Joaquin County Public Nealth Services. /J 1 Job Address p-Gvt�ti 1�✓�. 3� City S�'�r� Lot Size/Acre r Owner's Name "�� _ Address �81.1Gt+ �t K-�CDL s Lwpn 5 �{ Phone �� . Contra rL t`�CtU-t1•� Address �-�l �o3�1111 +C� [�'C 79DVI¢ License-NOL9 2$ Phonc��b1 ot- TYPE OF WELL/PUMP:_ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Out of Service Well ❑ �. PUMP INSTALLATION ❑ SYSTEM REPAIR C1 OTHER ❑ Monitoring well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 3t41 ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J��pj n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation �" 5 Dia. of Well Ce U Domestic/Private ❑ Gravel Pack n Tracy Type of Casing Specifications ❑ Public Cher ❑ Delta Depth of Grout Seal 0 Irrigation t A Type of Grout Approx.`,Depth ,❑ Eastern " Surface Seal installed by Repair Work Done U Type of Pump - H.P. State Work Done_ Well Destruction F Well Diameter ; Scaling Material i Depth f -r> "( ,Depth tt Filler Naterial 4 Depth TYPE OF SEPTIC WORK, 14EAk INSTALLATION 0 REPAIR lADDlTIUN LI DESTRUCTION C! INo septic system permitted it public sewer is r installation will serve: Other Residence" mmerciat - availabi . in 200 feet.) r Number of living units: -Number of be oms Character Of soil to a depth of 3 feet- 0 eet: ❑ SEPTIC TANK. ---Water table depth Type/Mig :.l Capacity No. Compartments PKG. TREATMENT PLT.❑ � t ,1 x Distance to nearest: Method of Disposal oundation Property Line f LEACHING LINE ❑ No. & Le of lines FILTER BED4 Total length/size ❑ Di ce to nearest: Well FoundationP I rgperty Line SEEPAGE PITS ! I Depth I Size SUMPS �= Number f Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 i rules and regulations of the Sen 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, I shall employ persons subject to workman's compensa- tion laws of California." ' The applicant must call for all required i/nspeecct—ions. Complete drawing on reverse side. Signed Title: Date:!� lZ�- ` ,_...� t FOR DEPARTMENT USE ONLY Application Accepted by Date A rem Pit or Grout Inspection by Date "ice Final Inspection by 3 f Additional Comments: Date Applicant - Return all copies to: I — P SAN JOAQUIN CO TY P LIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES Z� t 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 9`�� t FEE AMOUNT DUE AMOUNT REW7Eq INFO ASH ECEIVED 8t' DATE PERMIT'NO, I ER 13.24 Wv.