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� APPLICATION FOR PfiRYIT SAN 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 inatall the vork herein described. This application is made 1n 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-'1'y I S//�/ /Tl�i {✓/1Cj ,t � ��I7.o/t-Size/Acreage Owner's NameUSSl,L�r�AdAddress � � Phone —Fy 7/ Contractor / / Address 21;RZ� Z ill_. icense No. Phone 2 TYPE OF WELL/PUMP! NEW WELL ❑ WELL REPLACEMENT fl DESTRUCTION t of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 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 Well Casing n Domestic/Private ❑ Gravel Pack O Tracy Type of Casing Specifications I'l Public 171 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth I I Eastern - Surface Soul Installed by Repair Work Done U Type of Pump H.P. Sta�teF Work Oons�^ Well Destruction Well Diameter Sealing Material a Depth �cl1Lf„ / F,Q6m /f1"' Depth /S� Filler Material a Depth G�,J/'/ /� y,�,mps//�" TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sower is available within 200 feet.) / . f Q Installation will serve: Residence_ Commercial_ Other /e . Number of living units: _ Number of bedrooms /2G Character of soa to a depth of 3 feet: Water table depth f SEPTIC TANK. O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.0 - Method of Disposal -C Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No. g Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Lim SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Wag Foundation Property Line DISPOSAL PONDS 0 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 Hone owner or licensed agent's signature certifies the following: -1 certify that in the Performance of the work for which this permit is issued. I shall not • employ any person in such nennar as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: 1 certify that in the performance of the work for which this permit is issued, I shall employ Persons subject to workman's companss- tion laws of Celifomla:' The applicant mu required ' Complete drawing on rover ide. Signed � 1>S%l�l/lit da: /�iCQ —/ zeX Date: R DEPARTMENT USE ONLY NICI ,ItAAL�&— D�ats Application Accepted by � /G, Dats � _ ArePh or Grout Inspection by � to ' Z� Final Inspection by /1 Additional Commat Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N Sao Joaquin, P O Box 2009, Stka, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO ��\\ //�•t . . EH 11741AEV.r/a at Y� t V V �O t Vo SZ� —t6_ I` z 6 H Ilam