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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESD i. ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 RIhNIT ESPIRES I YEAR FROM DATE ,]ISSUED (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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 7� )15 l�-f� City Lot Size/Acreage la I Owner's Name � en Address 2� Phone 3 1 h GLS`D .5 �1 - ^Contractor L- Li Address U�� License No..!�.l33 Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLAC ENT 0 DESTRUCTION.❑ Out of-service Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE ' II FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r G 'fl Industrial Cl Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing I pLJ Domestic/Private ❑ Gravel Pack C3 Tracy Type of Casing Specifications ; kJ -1 Other Public ❑ Delta Depth of Grout Seal Type of Grout ; CI lrrioatjor' r _Approx. Depth ❑ Eastern Surface Seal installed by t ;r Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter sealing Material 4 Depth ^� li Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIRIADD1TION DESTRUCTION G (No septic system permitted if public sewer is available within 200 feet Installation will serve: -,Residence : Commercial_ Other' Number of living unpthoiti: d „,_Number of bedrooms Character of sail to a depth of 3 feet: Water table depth r SEPTIC TANK.. 1 ❑ Type/Mfg Capacity No. Compartments ' PKG. TREATMENT PLT.-0 Method of Disposal Distance to nearest; Well Foundation Property Line LEACHING.LINE No. 8 Length of lines Total Isngth/size— FILTER-BED izeFILTER f;ED n Distance to nearest: Well oundation Property Line SEEPAGE PITS A Depth Sire Number_ 10 s SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSA-C PONDS O j 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 ii 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 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 requir in Ctjons omplete drawing on reverse side, ' Date:.�L '9 7—'7Q % ; FOR DEPARTMENT USE ONLY G Application Accepted by Date Area PIt of Grout Inspection by r Data Final Inspection by ,' Date r } Additional Comments: y Applicant - Return all copies to; SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON. CA 88201 FEE INFO AMOUNT DUE AMOUNT REMIT CEO CASH RECEIVED 8Y DAT f PERM17'N0. . EH 1J•71 fREV.+iwsl 'yt. / ALI f /