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APPLICATION SAN �6AQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 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 complealthiSery with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address r. ( �i '� — City l�(C �ti Lot Size/Acreage !L1 &/• _ Owner's Name ) Address r.-. J sl7C Phone Contractors?Ck,-Jtr/WC!'�Ii A -'D Address rtC4 6k: C 7 ZcY: f `' N License No. % �f r - TYPE OF WELL/PUMP: NEW WELL ❑ �---f� Phone E L WELL REPLACRIENT n DESTRUCTION ❑ Out o' Service Well ❑ PUMP INSTALLATIO O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANKAL _ SEWER LINES ��' DISPOSAL FLO. A"/r'" PROP. LINE le' FOUNDATION /a t�� AGRICULTURE WELL LLL_ OTHER WELL PITS/SUMPS � INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C) Industrial ❑ Open Bottom ❑ Manteca Dia. of WeB Excavation r Domestic/Private 0 Gravel Pack ❑ Trac Dia. of Well Casing ri V Type of Casing �C Ste__ I'] Public Cl OtherCi DSpecifications / Delta Depth of Grout Seal :L Type of Grou$!� �If;y>C •7 i Repair Work Done U Type of Pump I I Irrigation _Approx. Depth Eastern Surface Seal Installed by A�r rte` ,.; f:, �,. ., T.� H.A. Well Destruction ❑ Weli Diameter State Work Done _ Sealing Material & Depth Depth Filler Material Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADOITION I I DESTRUCTION I I (No septic system permitted it public sewer is Installation will serve: Residence_ Commercial_ E;ti er available within 200 feet.) Number of living units: Number of bedrooms Character of coil to a depth of 3 feet: SEPTIC TANK ❑ TWater table depth •b Type/Mfg PKG. TREATMENT PLT. ❑ Capacity. No. Compartments --� Distance to nearest: WellMethod of Disposal Foundation Property Line LEACHING LINE 0 No. 8 Length of lines FILTER BEDTotal length/size O Distance to nearest; Well Foundation - Property Line SEEPAGE PITS 11 Depth Size SUMPSLI DiNumber Distance to nearest: Well Foundation DISPOSAL PONDS ❑ ------ Property Line 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 subcontracting 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 II toil requirec,i Spections. Complete drawing on reverse side. Signed l�` �^ Title: f� 1 / Date: _` 7 `� FOR DEPARTMENT USE ONLY Sr 2C?(]a Application Accepted by ? 1 Cr� Area L)A 1+ O t / Pit or Grout Inspection by Date Date Final Inspection by Additional Comments: Date Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE �/�/ /� ��[/ %� yt PERMIT NO. 324(REV.4/MSI $i O lJ /� L,J 11)22 �A 1 1I-2e V /t/4 3 -i• 9 3 �--02g�