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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 9MIXi 9MIA95- X YEAR FROM DATE ll—a= (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This M40 application is de in cottlpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address Pr JA (e h 4 +rP• City Lot Size/Acreage Owner's NameWA L[OIV �l�/ � D 0 w o�, Address _�� ~��t�� k r ' Phone a-d � 1 Contractor__!Ze (if;!— Address A d P t PV01(t0 %AP4 • License No. Phone 3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial Cl Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing - �^ U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications a M Public EI Other p Delta Depth of Grout Seal Type of Grout CI Irrigation �.ApprcK, Depth ❑ Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H,P. State Work Done_ Will Destruction ❑ Well Diameter Sealing Material A Depth Depth Filler Materiel i Depth ; I TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION M DESTRUCTION. (No septic system permitted if public sewer is available within 200 feet.! Installation will serve: Residence.— Commercial— Other Number of living units: Number of bedrooms # Character of soil to a depth of 3 feet: 6 f Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT, 0 Method of Disposal Distance to nearest: -Well Foundation Property Line f ` LEACHING LINE 0 No. 8 Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 11 Depth Size 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 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 subcontracting 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." -F - The applicant must �ca for all rrequir in pact' Complete drawing on reverse side. Signed Yt/M 4" - y"9 Title: Date: o — 1 S- 90 — n DEPARTMENT USE ONLY 4 Application Accepted by Date Araa Pit or Grout Inspection by Dat Final Inspection byDate:F4a Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. . EHU•24fREV.iiKsl Ek;1.26