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APPLICATION FOR PERMIT < SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 I k pl"IT URIRTS 1 YEAR 5SUSD (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 x Joaquin County Public Health Services. t V10 CD-a-faR 2c Lot Size/Acreage to Z Job Address SSS r �e"`� City I k Owner's Name ' a �l Address es S�QsftaiT 6--/C Phone yes 5 7�A6 a Contractor �8 '�"� Address l t'D F it 54-• SLJCt g,'ALicense No. a0-2 iOPhone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION ❑ Out of erice Monit ving Well ❑ PUMPINSTALLATION ❑ SYSTEM REPAIR C1 OTHER ❑ I��IL S 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 err t 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing {J Domestic lPrivate Gravel Pack Tracy Type of Casing �C 5`L.r��tC specificationss�� ❑ Public 1-1 Other 1000118 Depth of Grout Seat S Type of Grout "''vim-� � CI Irrigation _... Approx. Depth C1 Eastern Surface Sedl Installed by Repair Work Done U Type of Pump �� H.P. State Work Done ? Sealing Material 6 Depth �w�� Well Destruction D Welt Diameter 2 Depth "2fl Filler Material i Depth �,o�.�ere x-26 k TYPE Of SEPTIC WORK: NEW'INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION 1-1 ave septicable ssystem feet.) if public sewer is Installation will serve: Residence i Commercial_ Other Number of living units; Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 1, SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 . j Method of Disposal Distance to nearest: Well Foundation Property Line f t length/size LEACHING LINE Cl Na. & Length of lines Total len 9 FILTER BED ❑ Distance to nearest: Well Foundation Property Line t " SEEPAGE PITS 11 Depth Sire Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ f I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and 1O rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the port ormance 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 sub-contracting signature certifies the following: "I comity that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compenas- tion laws of California." The applicant must call for all required inspgctions, Complete drawing on reverse side'. ' Signed X Title: -f 2 >� � r5 Date:. --- - DEP ENT USE ONLY Application Accepted by Date A a l- L Pit or Grout Inspection by Dat Final Inspection b Data Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES t ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2000, STOCKTON, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERIMIT.NO. INFO M (� fj7 . EH 1 .74(REV.iins) M �e( .ba [ �Od .... y t , r]� 5'2� 1 —117:1 fH 7474 � �1 r