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APPLICATION FOR PERM SAN JOAQUI PUBLIC HEALTH SERVICES ENTAL HEALTH DIVISION ON AVE. , PHONE (209)468-3420 o iia 009, STOCKTON, CA 95201 ,+"�►t iIf RES 1 YEAR FROM DATE ISSUED S4�C,1t� (Complete in Triplicate) Application in he 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 Serviced. r� Job Address �r .7.5 L C A r4 rte✓ WA 4 City SfOC.�c T)Gn Lot Size/Acreage Owner's Name . S�fan lc., /tijO[r t Address y�'.2j LJ a- f rPhone 9 Contractor If C e ddress 2 kZf /V, i• e A License No. / Phone-Itr//E. - TYPE OF WEL /PUMP: NEW WELL ❑ WELL REPLACEMENT fl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well DISTANCE TO NEAREST: SEPTIC TANK '5,0 SEWER LINES .S C DISPOSAL FLD. PROP. LINE _,.5_ FOUNDATION /C AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C.I Domestic/Private 0� Gravel Pack L1 Tracy Type of Casing �� G Specifications — CI CI Public 0 Other n Delta Depth of Grout Seal Type of Grout — I I Irrigation SO t:gpprox. Depth I I Eastern Surface Seul Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth C Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mtg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No. & Length of lines Total length/size , FILTER BED LI Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby cenity 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 canities 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, 1 shall employ persona subject to workman's compensa. tion laws of California." The applicant mun�ll for all required inspect ons. Complete drawing on reverse side. q Signed X / Gl�'�-�e'� Title: � - �=--- - .p:�r�— - Date: 6 `7 0 D MENT USE ONLY ��- Application Accepted by Date `� r a Pit or Grout Inspection by G:� Date -?b'% Final Inspection by, Datg1 'Z_ 0 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Razelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH CX�Kil r RECEIVED BY DATE 7 PERMI7 NO. 1 . e.,12-24IREV.Ir Met INFOllU�/ CXX`�//D �( �u"� 1 EH .4.26 C/