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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES D Q ENVIRONMENTAL HEALTH DIVISION Cv I 445 N SAN JOAQUIN, PHONE (209)468-3420 'F�Y r?N� P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby wade to San Joaquin County for a permit to construct and/or install the vork 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 / � City Got Size/Acreage ,V Owner's Name f()e i:, L M 1 Z d .SUSS Address / Xrl.Zu SQ Phone Contractor _SP Address .��(/l7 _ License No. Phone q TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT (-1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR 7( OT(;�E�R nitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. E~' FOUNDATION AGRICULTURE WELL _X_— OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial fid Open Bottom O Manteca Dia. of Well Excavation T Dia. of Well Casing (I Domestic/Private Ll Gravel Pack O Tracy Type of Casing_. ,S Ub KAOwellepecifications i- I'I Public 17 Other fik Delta Depth of Grout Seal V11 k4o WA_ Type of Grout «,,ntelf \ I1$ 3iL Irri ation r V Approx. Depth I I Eastern Surface Seal Installed by Sc'/yo Repair Work Done U Type of Pump 1/d6ow" H.P. _ :2 o State Work Done C_&A4 y fo /900 At!gJ —� Well Destruction O Well Diameter Sealing Material i Depth NSI&k.)-•✓ 1 o)iSChti Depth Tiller Material li Depth if TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I (No seplic system permitted if public sewer is Installation will serve- Residence _ Commercial Other available within 200 feet.) Number of living units: Number of bedrooms Character of soli to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. i Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS It Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O I hereby certify that 1 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 subcontracting 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 mu t call for all requir d inspections. Complete drawing on reverse side,. G� U Signed X Title: Q l�l_1 r 1.`T�� Date: T Ol 7 J %� ^ OR DEPARTMENT USE ONLY Q C� ^� Application Accepted by ("i�Y\1f`�a L J+� Date 1 11 1 Z Area Pit or Grout Inspection by Date Final Inspection by Data Z Additional Comments: A-t* Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT NO. EHts�raEv -�sr r ��rc� , 23( '� A