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d ' APPLICATION FOR PERMIT � "- SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES { ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 R k Coat lete in Triplicate) } f � P Application is hereby made.to San Joaquin County for a permit to construct and/or ina� he lik sipp des�rPA. This : application 1e made in catrg+liance with San Joaquin County Ordinance No. 549 and 1$62 at �dit�t�" as R' atlona of San Joaqula County Public Health Services. Job Address City Lot Size/A, 14%; . 'V1 Owner's Name ?�,LY ' _ Address Phone17 - 6 r�u Contractor Address Y-G A License No/6 L3?3 T�Phol 1 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT M_ DESTRUCTION ❑ Out of Service well 0 PUMP INSTALLATIONAd' SYSTEM REPAIR Cl OTHER ❑ Moni'toring Well L� DISTANCE TO NEAREST: SEPTIC TANK w SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS " INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial--, ❑ Open Bottom t C] Maniacs Dia, of Well Excavation Dia. of Weil Casing U Domestic/Private 0 Gravel Pack. +❑ Tracy Type of Casing Specifications ZI Public I-1 Other ❑ Delta Depth of Grout Seal Type of Grout mnfrigation ?Approx. Dept ❑ Eastern Surface Seal Installed by - t Repair Work Done L3-- Typo of Pump , H.P. Z G State Work Done Well Destruction 0 Well Diameter Sealing Material i Depth •. �,'='-_�: �._:-..-,.�..=��pth 11izr-Materisl-i-i3eptYt—=�-.-.�v�-r«....... - "�=�---'� w-r,.... M � _ TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION ❑ DESTRUCTION CJ INo septic system permitted if public sewer is ' d available within 2W feet.] Installation will serve:: Residence— Commercial— Other Number-of-living units: Number of bedrooms 3 F Character of soil to a depth of 3 feet: Water table depth '� SEPTIC TANK. O Type/Mfg Capacity No. Compartments _ PKG. TREATMENT PLT.Cl Method of Disposal Distance to nearest: Well Foundation Property Line ^� LEACHING LINE 0 No`8 Length of lines Total IengtKisize •_.ki, FILTER BED {`` ❑ Distance,to nearest: Well Foundation Property Line SEEPAGE PITS!TS i I Depth 5ira 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 Joaquin County h 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 subjict to workman's compensation laws of California," Contractor's hiring of 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 must call for all required inspections. Complete drawing on reverse side, p Signed X LUL _ i _,.. '-Z -_3 Ir U Date: _ EPPI DEPARTMENT USE ONLY r, Application Accepted by Date a Area Pit or Grout Inspection by Date Final Inspection by'/ _e,- __ Date 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 98201 INFO AMOUNT DUE AMOUNT REMITTED GASYf RECEiyEO BY DATE PERMIT N0. . EH t374 iREv.iiROi fN ,� / f12'*Cf !I :1•le