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0 APPLICATION FOR PERMIT SAN JOAQUIN 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 lilt (Complete in Triplicate) Application is hereby sada to Sao Joaquin County for a peralt to construct and/or install the work herein described. This application is stade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Public Health Services. /J Job Address —J � 7 A �A l �l I1CG 19-5- 2 � ,t`City�� Wtt�Size/Acreage fa az -- Job Nartr M� i :C4F LjQJC?Jqy Add``ress/9%- 2/-1i-2te RVG>t- !c-c Ph�oone - 9 -� C pacts l- O fN Address�V UOv[ C{a C)OI 1 License No. .,. Rhone-- 622- PE OF WELL/PUMP: NEW WELL, WELL REPLACEMENT DESTRUCTION Out of Service Well ❑ PUMP INSTALLATION X SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ O,STANCE TO NEAREST: SEPTIC TANK SEWER LINES �/�� DISPOSAL FLD. PROP. LINES 0�s/ 1. y FOUNDATION AGRICULTURE WELL -f OTHER WELL PITS/SUMPS Iy INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L�Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wall Casing - Domestic/Private ❑ Grave Pack ❑ Tracy Type of Casing {yee-/ Specifications Public I:7 Other fl Delta Depth of Grout Seal (Type o11[,rout I I1! nation tion Approx. Depth I Eastern / urface Seal Installed Dy l 1 ( „G Rapes Work Done U Type of Pump H,P. Statq W k Don WAN Destruction X WaN Diameter Sealing Material A Depth x T DepthIF!y filler Material A Depth T PE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I I DESTRUCTION I I fNo septic system permitted if public sewer is available within 200 fest.) instWtion swill verve: Residence_ Commercial_ Other lilurnipair of Ewing units. _ Number of bedrooms thatramcfew of moll to•depth of 3 fest: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PILO. TREATMENT PLT.❑ Method of Disposal tl Distance to merest; Well Foundation Property Line ,FIiCHINP LINE ❑ No. 8 Length of lines Total length/size FILTER SED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to merest: Well Foundation Property Lina 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 rues and regulations of the San Joaquin County HanN owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in much manner as to become subject to workman's compensation laws of California.” Contractor's hiring or sub-contracting signature certifise ft following:"I cenity that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compense- don lam of Californlm." The applicant mustalllffor all required ins coons. Complete drawing on reverse side, � S'g Od /V / /,i JA/1/11 tQ"�_ Title: �.] !?L/Y P C=AS Date: ` • /� FOR DEPARTMENT USE ONLY Application Accepted by (o�� ~� Date -2-- \'k-ZkL Area PN or Grout Inspection by ate Z'I Z- Final Inspection by "" G 4 Data d L Addhionsl Commsnu: CI .o D !•r r Applicant - Return al cop) to: San Joaquin County Public Health Services Environmental Health xt/Servs tee 0 Bo N Sao Joaquin, P O Box 2009, Stkn, GA 95201 FEE AMOUNT DUE AMOUNT REMITTED Cx R RECESit IVED DY DATE PERMITNO. f"? / INFO • EN I1N IAN.irea� `/.�� , 1 �'.bU � rQ (� � i//[,� �� _ 9a� fR N->t