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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES f� 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 cetspliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of'San Joaquin County Public Health Services. Job Address �x 1��/'tf70/"� 'f/Y. City Lot Size/Acreage Owner's Name •�� f - Address f d �� J� !'�{/^ Phone Contractor /trJP9 AddressXeli! K License No. Phone '� Pa TYPE OF WELL/PUMP: NEW WELLZW WELL REPLACEMENT ❑ DESTRUCTION Out of Service Nell O PUMP INSTALLATION 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 D Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private 0 Gravel Pack O Tracy Type of Casing_ Specifications t j ('1 Public Cl Other rl Delta Depth of Grout Seal Type of Grout I 1 Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. Stats Work Done_ �) Well Destruction O Well Diameter4 Sealing Material i Depth 1t /+ !v Depth 7 2- Piller Material i Depth k�1 ,A '216 p'1 cel r vo TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) �n Installation will serve: Residence_ Commercial_ Other LJ Number of living units: Number of bedrooms Chsracter of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. 8 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 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 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 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 >it o 1 fo I requ' tnspsctions. Com late drawing on re erss side. n Signed Title: �� Date: 2-- Q� \Q\R DEPARTMENT USE ONLY y Application Accepted byy`^ ��1�Annn�.t�.� Date I N. 1 -`p Z res l Pit or Grout Inspection by Date Final Inspection by Date%26� Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED / ASH RECEIVED BY DATE PERM17'NO. . EM 1174 IIIEV.v M bl 4 -- --- 4 EH 14.70