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APPLICATION FOR PERMIT 1 S. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION AA1 W�Il P O BOX 2009, STOCKTON, CA 95201 &3_4k Ale P/r3 (209) 468-3447 PERMIT ESPIRES 1 YEAR PROM DATE ISSUE (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 In made in compliance with San Joaquin County Ordinance No. 549 and 1962 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address -2 3`L IU. 0720 S'7- City 5 7Xn/ Lot Size/Acreage Owner's Name Address Phone Contractor_. �'.�_6. �ae,a Address J .✓ AA_-��.�7 License Ido. !��i7L Phone _g 3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM EPAIR ❑ OTHER p Monitoring Well (7 DISTANCE TO NEAREST; SEPTIC TANK k SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION A ICULTUR ELL OTHER WELL PtTSISUMPS INTENDED USE TYPE OF WELL. PROBLEM A A CONSTRUCTION SPECIFICATIONS * Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing * Domestic/Private ❑ Gravel Peck ❑ Tracy pe of Casing Specifications (f� * Public CI Other ❑ Del + De of Grout Seal - Type of Grout - n Irrioation Approx. Depth ❑ stern Surface Seal Installed by Repair Work Done L3 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material Z Depth TYPE OF SEPTIC WORK; NEW INSTALLATION 0 REPA+RIADDITION M DESTRUCTION (No septic system permitted if public sewer is available within 200 lost.l Installation will serve: Residence Commercial— Other 6 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth r SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.C] Method of Disposal , Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. A Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS a I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state taws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature cenifies 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 toibecorria subject to workman's compensation laws of Cahlornia." Contractor's hiring or sub-contracting signature certifies the following; "I Certify that in the peffofmance of the work for which this permit is issued. I shall employ persons subject to workman's compensa- tion laws of Californle." The applicant must cap for all required innsspKtionss.. Complete drawing on reverse side. Signed S� `f/rr. / Title: J� �- --- - - - Date: rZZ OR DEPARTMENT USE ONLY Application Accepted by _ Date 9'Q -` Area 1 �/ Pit or Grout Inspection by Date Final Inspection by' Data �` `U Additional Comments. Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 95201FEE fy� INFO AMOUNT DUE AMOUNT,REEMM/IITTED CASH AECEtVEO BY DATE PERMIVNO. . EH 13-24 iREv.Iin51 � W . q1 `,'� EH:4.26 f [[ i