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APPLICATION FOR PERMI'._ -Q:,N JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. y Job Address Z Gel S6 Sew f s �n City C� �'�r Lot Size/Acreage /0 Owner's Name .11A c p,,✓,, .Addddress �i SQ/V1C Phone //Z- �6 Contractorl� �Sp Address r`�8� �7d License No. ?773,fs Phone33Y` Y72- TYPE OF WELL/PUMP NEW WELL WELL REPLACEMENT M DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE So 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 e Dia. of Well Casin 4pYDomestic/Private Gravel Pack L-1TracyType of Casing_. p�G Specifications ;&L -yfJ I'I Public (1 Other n Delta Depth of Grout Seal S O Type of Grout I I Irrigation 3 7 Approx. Depth I I Eastern Surface Seal Installed by G)A.-7-0-A C 75— Repair —Repair Work Done U Type of Pump S-L,6 H.P. s State Work Done es��•�� Well Destruction ❑ Well Diameter Sealing Material i Depth V Depth Filler Material t Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) t Installation will serve: Residence_ Commercial_ Other v Number of living units: Number of bedrooms Character of sod to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line V LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line S SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 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 must call for all�required inspections. Complete drawing on reverse side. Signed X`�Z //.��- Title: 9 CA,-A,,-L Date: F R DEPARTMENT USE ONLY Application Accepted by � l� Date Area L Pit orro Inspection by Date/2 Z i? Y _ Final Inspection by " Date) L'L Z-9 Y Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE Li AMOUNT DUE AMOUNT REMITTED CK 11 1 CASH RECEIVED BY DATE PERMIT O EH 13-24 1REV.I/It 5, — 11 7 7� r `>L _ IE: �! - EH ,..2E I 1-`i`. .