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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201tS r (209) 468-3447 PERMIT EXP_LRE-3 1 YEAR FROM DATE IS511ED (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 In trade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin Coy j Public wealth Services. CIPC,� �7 Job Address MOM City +ot Size/Acreage Owner's Name - Aezk 4, ?Address 741 Phone Contractor Address License No. Phone Z TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTIONYXOut of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 17 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LENS FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 Indust6al i ❑ Open Bottom ❑ Manteca Die, of Well Excavation Dia. of Well Casing U Domestic/Private Q Gravel Pack ❑ Tracy Type of Casing - Specifications Z) Public. Cl Other ❑ Delta Depth of Grout Seal Type of Grout M Irrigation Approx, Dap h Eastern Surface Seal Installed by cyC Repair Work Done U Type of Pum /( H.P. State Work Done f Well Destruction )vWell Diameter .3 Sealing Material & Depth /97 Depth �z r f Filler Material & Depth ` TYPE OF:SEPTIC WORK: NEW INSTALLATION 0 REPAIR/AODITION 0 DESTRUCTION Ci lNo-septic systempermitted it public sower is available within 200 feet.1 Installation will serve: Residence T.., Commercial- --— Other ' Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS I l Depth Sire I Number C 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 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 applies t req ns. Complete drawing on reverse ide, Signed Title: Date: 7R DEPARTMENT USE ONLY Application Accepted by ADate Area Pit or Grout Inspection by Date Final Inspection by Date Zf QQ 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 2009, STOCKTON, CA 99201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT'N�O, Err ta•a,uay. �re� � q-1 Z p-0 efO— � Z� Ell^,•?e