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APPLICATION FOR PERMIT SAN`ttAQUIN COUNTY 'PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION JO BOX 2009, STOCKTON, CA 95201 (209) 468-3447 O IRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is an Joaquin County for a permit to construct and/or install the work herein described. This application is s in Mance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County ealth LServices. Job Address / CoZ�fr4 ca .Drive- City �orluA Lot Size/Acreage Q 1 d0o`X- Owner's Name v 01 ��• Address M-4 ►r°' f,44k Dr. Phone( o/-0 Q Q4 Ue Contractor S� r! Address Slim / License No. 1 o_76JD Phono j g�`�g�0 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION O Out of Service well 0 PUMP INSTALLATION O /WM A/�,SYSTEM REPAIR O OTHER O Monitoring well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES L'fS�r DISPOSAL FLO. �j� PROP. LINE FOUNDATION /OG AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L d n Industrial O Open Bottom O Manteca Dia. of Well Excavation /Z' Dia. of Well Casting/ T L) Domestic/Private rev ac O Tracy Type of Casing -5--A fLI* Specifications ("l Other ❑ Delta Depth of Grout Seal Type of Grout gaw"±4P Lit Approx. Depth ❑ Eastern Surface Seal Installed by •iw_4m�e Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADOITI 0 DESTRUCTION O (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Q Number of living units: Number of bedrooms (A Character of sod to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.C1 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. b Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Siza Number _ R SUMPS LI Distance to nearest: Wel Foundation Property Line DISPOSAL PONDS O I hereby certify that I have prepared this application and that the work will 6e 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: "1 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 cenify 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 applica st call';or 1 req -red in ctions omplete drawing on rover si _, Signed Title: (/> Date: DEP MENT USE ONLY / C/ Application Accepted by Date !�J_14:�2_ Area J Pit or Grout inspectan byUj�d' r _ Dat 37L �_,_,J Final Inspection b ,_ DauAdditional Comments: Z' 2 t �~ f f6' y 'G Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 448 N SAN JOAQUIN, P O BOX 2009, STOCKTON,, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK + RECEIVED BY DATE PERMIT NO. INFO CASH . EH 13.24IREV.1/A0) EM :�•2e