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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 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 ie made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address _ 2u eALor»A - - - - --- -- -_- City Lot Size/Acreage 1,,O'X -q47 Owner's Name AoW,0 BRA m l e7- Address- s.�Al- - _ -__. Phone - f Contractor _ FL-OYJ� l[JsdD Address 7AA ,4te4.B�Ar��6 License No. �fy7� - Phone 3 TYPE OF WELLIPUMP: w NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 F1 Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack n Tracy Type of Casing Specifications — M Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout M Irrigation _Approx, Depth 0 Eastern Surface Seal Installed by Repair Work Done v Type of Pump H.P. _" State Work Done _ Wall Destruction Q Well Diameter Sealing Material i Depth 1 Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR 1ADDITIONX DESTRUCTION CI INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence '/ Commercial Other Number of living units: _� Number of bedrooms -3 Character of $oil to a depth of 3 feet: (2 _ Water table depth SEPTIC TANK O Type/Mfg L'e — PSL Capacity 1-Q a No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well PD �` Foundation S Property Lina 2a LEACHING LINE No. & Length of lines -tr___ ' Total length/size exz �$R FILTER BED I:1 Distance to nearest: Well &PA�! --'- Foundation f D Propeny Line __-45' SEEPAGE PITS I Depth Size ZI Number SUMPS Ul Distance to nearest: Well Z cll� Foundation �0e Property Line g 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 Joaquin County Horne owner or licensed agent's signature certifies the following: "I cenify 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 peitormance 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 inspections. Complete drawing on reverse side. Signed X Title: Date: 2 "2"'9F FOR DEPARTMENT USE ONLY Application Accepted by Date I Area - Pit or Grout Inspection by `` Date Final lnsp - - Data Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLICARALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERIIIIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON. CA 95201 FEE INFO AMOUNT DUCE AMOUNT REffM''iTTEO CAS�>i( REECEIV�ED y8Y DA`T�(E ] PEA/M`IIT IVO. EH 13.2401 EV.,,x 5) - ©�--. - - , �� VV-. 114 ' V P -t f 'vt�J 0 -�l] qlIql _v lj� EH 74.26