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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES i� ENVIRONMENTAL HEALTH DIVISION P O BOX 20094 STOCKTON, CA 95201 (209) 468-3447 t � , 1 YEAR rROM DATE IbUVEDw t1. (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 complianceJvlth San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban Joaquin County Public Health services. .i Job Address `3 S ,S, �D�` d— City <A-1 Lot Size/Acreage .lo h w 7. Owner's Name Z A r �' � Address 2 72 Pam!' rc do. Phone ��'y�y3 FLO Contractorflt�'--oi�s I Address .27d �rt b License No.� � Phone G TYPE OF WELL/PUMP: NEW WELL C3 WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well Gl PUMP INSTALLATION XD SYSTEM REPAIR ❑ OTHER ❑ ; Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK{ 2s SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATiO6 AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLE AREA NSTRUCTION SPECIFICATIONS f} Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casings' U Domestic/Private CI Gravel Pack E3 Tr 'Type of Casing Specifications 13 Public i'1 Other � Delta Depth of Grout Seal Type of Grout If Ci Irrigation Approx. Dept ❑ Eastern urfaca Seul Installed by } Repair Work Done U Type of Pump r H.P. State Work Done'-- Sealing Well Destruction ❑ Well Dianne r Sealing i+ta itl fi Depth Depth ft Filler Materi i Depth `` M1' TYPE OF SEPTIC WORK: .NEW iNSTA1,LATION Ll REPAIR/ADDITION M DESTRUCTION (No septic system permitted if public sewer is r tt available within 200 feel.l Installation will serve: Residencer!'•Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg .f Capacity No, Compartments PKG, TREATMENT PLT. 0 Method-of Dispossl V Distance to nearest: Well Foundation Property Line t LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ;i i SEEPAGE PITS i l Depth f Sire Number SUMPS Ll 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 rules and regulations of the San Joequin'County J 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 canities the following: '•l certify that in tha performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." `� The ap ust I re ui ed inspections. Complete drawing on reWrse sid I� Signe Title: _ Date: u®r F DEPARTMENT USE ONLY Application Accepted by t Date yArea Pit or Grout inspection by Da Final inspection by Date �� Additional Comments: ! t'v 5z?.Lo Applicant - Return all copies to: 'SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES EENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES '945 N SAN JOAQUIN, P O BOX 2009, ST(CKTON, CA 85201 FEE; AMOUNT DUE AMOUNT REMITTED CASH NECEIVED BY DATE PERMIT NO, INFO / + EH 13.24INEV.�in5) t C7 t[C T /tj-f 1� a �� EK 114-24 [ �t