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I APPLICATION FOR PERMIT k } SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468--3447 ! . .PERMIT EXPIRES 1_XEAR fR__Ou PATH ISSUED f (Complete in Triplicate) Application is hereby made to Sail Joaquin County for a permit to construct and/or install the work herein described. This application is made in coma liance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. I Job Address la!:� /�Fl A nf- _ City �41,4QLot Size/Acreage Owner's Name A&-��-'-- C � -Address— Phone Contractor J, -* LL1GJ1J-vN Address License No._-JZ T Phone TYPE OF WELL/PUMP: _ NEW WELL ❑ _ .WELL_REPLACEMENT 71 ,DESTRUCTION ❑ Out. of Service Well ❑ PUMP INSTALLATION ❑ �`- f SY,6EM` REPAfR�'0 F':" '� OTHER ❑ Monitoring well LZ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE II FOUNDATION AGRICULTUREr1NELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CON STRUCTION_SPECIFICATION S:..._ n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ` U Domestic/Private 0 Gravel Pack n Tracy Type of Casing' Specifications M Public fel Other ❑ Delta Depth of Grout Seal ►Type of Grout G Irrigation .Approx, Oepth C) Eastern Surface Seal`Installed by.- i Repair Work Dana U Type of Pump - H.P• State Work Done Well Destruction D Well Diameter Sealing Material &r Depth Depth Filler Material i Depth l TYPE OF SEPTIC WORK: NEW INSTALLATION L'_ REPAIR/ADDITION M DESTRUCTION INo septic system permitted it public sewer is 1 , available within 200 feet.) Installation will serve: Residence Commercial— Other_ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/MfgCapacity No. Compartments PKG. TREATMENT PLT, Cl Y ` Method of Disposal Distance to nearest: 'Well Foundation T Property Line LEACHING LINE C) No. & Length of lines Total length/size FILTER BED 1=) Distance to nearest,. !WellFo ndation Property Line SEEPAGE PITS 11 Depth l tSize _ E.. Number SUMPS Li Distance tornearest: Well Foundation Property Line DISPOSAL PONDS ❑ J , ._ 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, end 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 becoms subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance 6f the work for which this permit is issued, I shall employ persons-subject to workman's compensa- tion laws of California." A' �~ The applies t ust calf ora r quir d i � coons, Complete-drawing on reverse side, ... .. Signed Title: _raf�t_ _ Date: •]' F DEPARTMENT USE ONLY r „ Application Accepted by `'"� Date `�3_4 Area Pit or Grout Inspection by Date Final Inspection by CL Date 161 Additional Comments: Applicant - Return &U copies to. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES !ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 4445 N SAN JOAQUIN, P O BOX 2009, STUCKTON, CA 95201 IEEE AMOUNT DUE j AMOUNT REMITTED CK 9 CASHpp�� RECEIVED BY DATE PERMIT'NOEH P f� EHt,,-24 fREv.�iwer ,07f / cD�[ Zg�J Gn GD ?O `.�l� cLJ a I