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r APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION f 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 E PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ! Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in coapliance vith Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San" Joaquin County Public Health Servic e. Job Address zsgs—o r City 01125�111�61 Lot Size/Acreage Owner's Name VIC A/ 17 Address - -- - Phone 143_15;0 ys- Contractor Address L ce se No. Pho TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well a M PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Nonitoring Well ❑ I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION :AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS . 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wall Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Typei of Casing_ Specifications i I"1 Public n Other n Delta Depth of Grout Seal Type of Grout ,I I i Irrigation _.Approx. Depth I I Eastern Surface Said Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Wag Destruction O Well Diameter Sealing lfaterial i Depth Depth Filler Naterial i Depth F. TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUPT_lON I 1 (No septic system permitted if public sewer is available within 200 feet.! Installation wilt serve: Residence_ Commercial— Other ' I Number of living units: Number of bedrooms Character of sol to a depth of 3 feet: Water table depth SEPTIC TANK. . ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal ul Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No, 8 Length of lines Total length/size I FILTER BED � 0 -Distance to nearest: Well Foundation Property Line r SEEPAGE PITS I I Depth Sire Number SUMPS L1 Distance to neprest, Welilve Foundation -- I Property Lins DISPOSAL PONDS ❑ 1Q 3 0 .3 d "P-e.ep 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 a 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 eertifiq 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 appf ntaa 'It for trona. Complete drawing on reverse side. / Signer lf� i Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by �7 Date Area or21 out tion by -4,:2 M� Date l/•� -Final Inspection by Dats � ZJ Additional Comments: ' Applicant - Return a1L'eopies to: San Joaquin County Public Health Services Environmental Health Permit/Services w 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 ` IFEEO AMOUNT DVE AMOUNT REMITTED CK RECEIVED SY DA E PERMIT NO. `vim`'• • Eli 13-24 IREY.I/e sl / / `J .r . EH 14.76 / `.