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APPLICATION FOR PERF I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 MAR (209) 468-3447 EWRONfILC-1 TAI 17x�L. 1 R PER MITI/SERYfCES (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 =40 in cot ;lance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public)Qo Health Services. Job Address City Lot Size/Acreage Or � I � rt . Owner's Name dress o`-1�g' So' _ Phone C' I g _a Conlrat tOr Address v +, ez 20 License No.J!S? ,2 4 24 Phone d TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION 0 SYSTEM REPAIR OTHER 0 Monitoring Well U 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 Cl Industrial ❑ Open Bottom ❑ man teca Dia. of Well Excavation Dia. of Well Casing Ll Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f� Public f-1 Other ❑ Delta Depth of Grout Seal Type of Grout GI Irrigation "Approx. Depth ❑ Eastern Surface Saul Installed by Repair Work Done Type of Pump �} H.Pa.. _. State Work Done Of Well Destruction O Well Diameter Sealing Material i Depth Depth �� Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION CT DESTRUCTION CI (No septic system permitted if public sewer is available within 200 feet.; Installation will serve: Residence_ Commercial Other _.,, d � Number of living units: Number of bedrooms Character of Boil to a depth of 31 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity- No, Compartments PKG, TREATMENT PLT, Ci II T '^ Method of Disposal Distance to nearest: Well Foundation .Property Line P LEACHING LINE L1 No. $ Length of lines Total length/size FILTER BED i I Distance to nearest: Well Foundation Property Line k SEEPAGE PITSI I Depth Size Number SUMPS LI 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 laws ws Joaquin county ordinances, s , and ' rules and regulations of the San Joaquin County , Home owner or licensed agent's signature certifies the following; "I certify lKai 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: "l certifythatlin the Performance of the work for which this permit is issued, I shali employ_ p y persons subject to workman's compensa tion laws of California." ,- •-� The applicant must call for I required ins a tions, Complete drawing on rev rse side: 1 II q! Signed - Title: "1 l r II� Date: h F R EPARTMENT USE ONLY Application Accepted by II Date44�� Area Pit or Grout inspection by H� Date Final Inspection by Date !7 Additional Comments: . Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES r a 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON. CA 85201 FEECx f. INFO AMOUNT DOE AMOUNT REMITTED CASH RECEIVED 6Y DATE PERMIT'N0. fy& t . EM 13.24 IREV. QI 1 t Q l F� O EH'/-2e ` IIail