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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I ENVIRONMENTAL HEALTH DIVISION 1445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERM T E%PIRES I yEAR FROM D TE (Complete in Triplicate) . 1 Application is hereby made to San'Joaquin County for a permit to construct and/or install thcvork herein described. This application is made in car�liance with San Joaquin Count Ordinance No. 5b and 1 in Joaquin County Public Health Be L' y 9 $ and the Rules and Regulations of San 378$ �'a� t/ Job Address Z0`j City t Lot Size/Acreage /x aa. Owner's Name Ul70ca/ r' Address PQ Box .�/��s'al7�Q/2o9dq Phone 6/c> Zy :y2,501 Contractor e7T H Address .2/�d W 4h TA j A-ePhon- 793 License No, S'/O -7 7Sp TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F7 DESTRUCTION Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK ❑ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial p Open Bottom ❑ Manteca pia. of Well Excavation V j f-I Domestic/Private ❑ Gravel Pack[ Dia. of Well Casing j[ E7 Tracy Type of Casing Specifications — I Public [� Other fl Delta Depth of Grout Seal I I Irrigation Type of Grout i Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump f H.P. State Work Done w Well Destruction ❑ Well Diameter I Sealing Material`i Depth - Depth Filler Material & Depth �+ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 1 DESTRUCTION INo sePlic system permitted it public sewer is t� available within 200 feet.) Installation will serve: Residence— Commercial„ Other Number of living units: 'LVA Number of bedrooms~ [N Character of soft to a depth of 3 feet: a /aarrr # SEPTIC TANK. ❑ Type/Mfg i Water table depth X. PKG. TREATMENT PLT.❑ I Capacity VnXi�to,r<�h No. Compartments r Method of Disposal Distance to niarest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Tota! length/size ce l.✓M FILTER BED 0 Distanto nearest: WON Foundation } � Property Line SEEPAGE PITS 11 Depth Un /'t Size F` Number SUMPS Cl Distance to niiwsst: Well Foundation DISPOSAL PONDS ❑ 1 Property Line I hereby cenify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stats laws, end rules and regulations of the San Joaquin Court licty Home owner or licensed agent's'signature certifies the following: I certify that in the r � performance of the work for which this permit is issued, !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, 1 shall emptoy persons sub}act to workman's compensa tion tows of Californla." The"icanrnu, or an req ins a. Complete drawing on reverse side. ! Sig Title: Date. FOR DEPARTMENT USE ONLY Appy Date B �� A L Area Pit or Grout Inspection by Date _ Final Inspection by Dati Additional Comments: l oo0 Applicant - Return all copies to: San Joaquin my Public Health Ser es ? Environmental Health Permit/Services I} 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 IEE AMOUNT DUE ?AM LINT REMITTED CK INFO CASH RACE/IVSD BY OATTEE PERMIT'NO. + E+41721fREV.i/xbl S� Q�' ?(f n� 06 EH I3•Ze [ }