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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201' (209) 468-3447P00, J04nl, PERNIT EXPIRES 1 YEAR PROM DATE issul v/p,' p Ci4E' rNcG!IAjiy (Complete in Triplicate) E''rfiL, t 4�� Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described:', }iie 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 Services. Job Address W ef?it 6Y:L /fir eh N e— City J' Cl API Lot Size/Acreage / o c i-p-i � � // ^/ '/ T /J N� i�tla_'-' C7/79.3SS-16o3 Owner's Name r� Ns,,-1 /'f� a .-Ly+C, Address �d fl 4"A4- k� /iS7" Phone c� Z r3ZS Ear ��f1y r t- S Contractor_ Address_447��, C14 License No. 5�.2-•2 �� Phone K�_6 TYPE OF WELL/PUMP: NEW WELL 9� WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well r1 PUMP INSTALLATION ❑ SYSTEMAgAIB ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK T`� SEWER LINES Z25_ DISPOSAL FLO,- PROP. LINE /0'0 ellA FOUNDATION a AGRICULTURE WELL OTHER WELD PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation t r AR-P _ Dia. of Well Casin$ z U Domestic/Private Gravel Pack L3 Tracy Type of Casing G Specifications Scf `q0 M Public f Cl Other ❑ Delta Depth of Grout Seal C3 Type of Grout C' e • iI G Irrigation 18 4�1 Approx. Depth ❑ Eastern Surface Seal Installed by KP, r Repair Work Done U Type of Pump H.P. Stat W rk one Well Destruction ❑ Well Diameter Sealing Material i Depth 2- e r LjE Depth Filler Material i Depth .3 ^�1 TYPE OF PTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION CI (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/Mfg Capacity No. Compartments PKG, TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby comity 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 applicsLpft call for all requir d inspections. Complete drawing on reverse side. Signed Title: __ '�ll�l ' Date: Z L� FOR DEPARTMENT USE ONLY Application Accepted by w Date ` r Area Pit or Grout Inspection by Date 7 �� Final Inspection by-?,Yl 1 Date 9 �7 Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, 3 tJCKTON, CA 95201 FEEINFO AMOUNT DUE AMOUNT REMITTED CASH CE VED BY DATE PERMIT NO. t:M -26I� ,r �,.,,� A fN ,�•m