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APPLICATION FOR PERMIT SAN j-aQUIN COUNTY PUBLIC HEALTH SERVICES /J� l 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 (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. Job Address City S� «T�ry Lot Size/Acreage Owner's Name _(.� r r' /L T L;' U Address _1-72 (i 141))::6 r Phone Contractor P I E Rs v Address /'CU ►ACX fir" l �(� L-3�2 ' License No.L_�2_/�/7 Phone 1/S_21? TYPE OF WELL/PUMP: NEW WELLS WELL REPLACEMENT Ci DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK AZIA SEWER LINES 100" DISPOSAL FLO.- /VPROP. LINE La FOUNDATION AGRICULTURE WELL Al 1A OTHER WELL ' t PITS/SUMPS N24 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial CYO pen Bottom ❑ Manteca Dia. of Well Excavation ST " Dia. of Well Casing .2 Cl Domestic/Private ❑ Gravel Pack O Tracy Type of Casing P ki C I'] Public FI Other Specifications `9 Delta Depth of Grout Seal A I I Irnpation A YPe of Grout �Z Approx. Depth I I Eastern Surface Soul Installed by 1')tz i/ 1 ---z' Repair Work Done U Type of Pump N/Pl H.P. /V//)L - State Work Done _ Well Destruction O Well Diameter .� r/ Sealing Mlterial i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADOITION I I DESTRUCTION 1 1 (No septic system permitted it public sewer is Installation will serve: Residence_ Commercial available within 200 feet.) _ Other Number of lining units: Number of bedrooms (� Character of sod to a depth of 3 feet: SEPTIC TANK Water table depth ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal C Distance to nearest: Well Foundation Property Line LEACHING LINE LINE O No. b Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Weil Foundation DISPOSAL PONDS ❑ Property Line 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 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, 1 shall not employ any person in such manner as to become subject to workman's com certifies the fo ng: "I certify that in the performance of the work for which this per laws California." Contractor's hiring sub contracting signature tion laws of C ifornla.' Permit is issued, I shall employ persons subject to workman's compensa- The applica at/call for rsquif inspectionComplete drawing ort rave aid . Signed / r Title: Date: FOR DEPARTMENT USE ONLY /1 S-7 27 C� Application Accepted by Date �' �f ?j G —�_ Area Pit or Grout Inspection by Dates Final Inspection by Date _ Additional Comments: 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 AMOUNT DUEAMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMIT'NO. EH 1124(ltEV.i,Rs) �9. �( � �q.d d z4 0� �'�t.-� a.2�{.�3 q3-�2=� � EN t1•Za f .