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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENV I RONII ENTAL HEALTH DIVISION �. 445 N SAN JOAQUIN, PHONE (209)468-3420 { P O BOX 2009, STOCKTON, CA 95201 r PERMIT EXPIRES I. YEAR FROM DATE ISSRIM S_- (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 coatpliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. I' r r70 Job Address /e 77-2 City Zo Lot Size/Acreage _f Owner's Name LV"1 Address m r Phone I a } pI ! Contractor +L'Y 7�' llAddress a I N n d License No.3773� Phone 2 9- 97� ! TYPE OF WELL/PUMP: NEW WELL pe WELL REPLACEMENT ❑ DESTRUCTION c Out of Service Well 0 PUMP INSTALLATION.�K SYSTEM REPAIR El OTHER O Monitoring Well U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE _ .FOUNDATION_ _AGRICULTURE WELL BLJOTHER WELL. PITS/SUMPS `I INTENDED USE' � TYPE OF WELL PROS LEM-AREA..CONSTRUCTION;SPECIFICATIONS M Industrial ❑ Open Bottom 11Manieci Dia. of Well Excavation L Dia. of Well Casing 1*.ebomestic/Private ?@'Gravel Pack n Tracy Type of Casing- Specifications tL \ I'1 public / F f l Ot/her (1 Delta Depth of Grout Seal /�� Type of Grout «c I I Irrigatgn p�' Approx. Depth I i Eastern Surface Soul Installed by A Repair Work Done 0 Type of Pump H,P. Z F- State Work pone cA A00 Well Destruction ❑ Well Diameter Sealing Material i Depth. ! - Depth Tiller Material i Depth( . i TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIRIADDITION I I DESTRUCTION l I lNo septic system permitted if public sewer is r available within 200 feet.) Installation"wili serve: Residence— Commercial— Other lY= ;j Number of living units: Number of bedrooms I� I Character of veli to a depth of 3 feat: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity 'j� No. Compartments PKG. TREATMENT PLT.0 Method of Disposal X L Distance to nearest: Well Foundation Property Line ` f LEACHING LINE ❑ No. 6 Length of lines Total lengthlsize�"_.. + } 4 FILTER BED s 0 Distance to nearest: Well Foundation Property.Line x I + SEEPAGE PITSI 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 4 rules and regulations of the San Joaquin County . "1 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 workmen's compensation laws of'California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is is'ued, I shall employ persons subject to workman's compenss" tion laws of California." ' t The applicant riwst c L for required Inspections. Complete drawing on reverse side.�J r; l Signed Title: Date: l 3 a _q 3 �i I. FOR DEPARTMENT USE ONLY Application Accepted by _ Date Area -v! Pit Grout nspection by Datev7"3"'!3 Final Inspection b Data Additional Comments: 4L—V %u wa 1 a.ta.d'-d-d Applicant - Return all copieso: 5 San Joaquin County Public Health Services D II Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 952011 FEE AMOUNT DUE AMOVNT ftEMtrrEO CK RECEIVED BY D TE PERMIT NO. Yi INPO g /u/ 0 EH 324 IREVI I M si 1.•26 f Lf 5 _, "