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APPLICATION FOR PERMIT ^ , �..� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 0 PERMIT EXPIRES 1 -YEAR PROM DATE ISSO (Complete in Triplicate) Application Is hereby trade to San Joaquin County for a permit to construct and/or install ork 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 Services. � �- Job Address 1 16 (fOVyl�I( L.) L�1�� City ' Lk � Lot Size/Acreage 1 v 1 Address I 1 Owner's Name Phon� Contractor,? eC rum Address 2e2b 111Y�171Z-_ SZ License No. Phone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER D Monitoring Well X 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 Ll Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private O Gravel Pack ❑ Tracy Type of Casing Specifications D Public (I Other 0 Delta Depth of Grout Seal Type of Grout M Irrigation ._._ Approx. Depth � D Eastern Surface Seal Installed by Repair Work Done U Type of Pump , A,LI! H.P. State Work Done _ Well Destruction /A Well Diameter y Sealing Material Z Depth C r Depth 343 7_ — Biller Material ii Depth/ 2! T s aK� �Z-30�. TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION 0 DEST CTION C1 1110 septic system permitted if public sewer is available within 200 feet.) \Other Installation will serve: Residence _ Commercial Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Typo/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Q Method of Disposal Distance to nearest: Well F undation Property Line LEACHING LINE O No. b Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Founds ion Property Line SEEPAGE PITS 11 Depth Si Number SUMPS LI Distance to nearest: ell Foundations _ Property Line DISPOSAL PONDS ❑ 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 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 applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: _2111107,1 ��' Date: Z r FOR DEPARTMENT USE ONLY Application Accepted by 11� Date__�_ Ar Pit or Grout Inspection by Date �- Final Inspection Data Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 85201 FEE INFO AMOUNNTT DUE AMOUNT REMITTED CASH ECEIVED BY DATE PERMIT'NO. EH 13-24IREV.I/Msr ,(<t♦• ) EH 14-2111 •L�/