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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PEMIT EXPIRES 1 YEAR FROM DATE- ISSUED (Complete in Triplicate) Application is hereby made.to Sen 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. LA�1 Job Address ' IJAI � �� ad _ City CM Q Lot Size/Acreage �.I7 �- Owner's Name� �� [lf�ilIlii 0iAddress 1 p / C1�1 o PhoneVis_ Contractor 44tdress l/r IDBS 3 / #—At License No.��Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well �7 DISTANCE TO NEAREST: SEPTIC TANKt .1120� SEWER LINES 160 DISPOSAL FLD, SD ' PROP. LINE Li=' FOUNDATION Ltf�� AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial XOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weil Casing %Domestic/Private Gi Gravel Pack Ll Tracy Type of Casing STiF/F Specifications YZ4 F1 Public C7 Other 1"l Delta Depth of Grout Sea! ,!W f Type of Gro.. ll Irrigation _.Approx, Depth € I Eastern Surface Seal Installed bywon–ds wiq!/] Ved j%Lg ____ -2 Repair Work Done 0 Type of Pump .'IS'" h H.P. _ IV State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth 7 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I. DESTRUCTION i I INo septic system permitted if public sewer is 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/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal Distance to neatest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS 11 Depth Size Number SUMPS Lt Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state Janrules and regulations of the San Joaquin County Home owner or licensed agent's signature cenifies the following: "1 certify that in the performance of the work for which this permit is issued, salnot 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 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 st ca f r all re uired ins ctions. Complete drawing on reverse side. Title:4' Si Signed X Date: I g >` aN��A � ort, _9&7191 FOR DEPARTMENT USE ONLY pp�� Application Accepted by Date i' L—clArea T Pit or ro t Inspection by Date 54=6- �Z' Final Inspection by t Additional Comments: Applicant �- Return all copies to: San J ' pp p Joaquin County Public Health j Services. Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009. Stockton, CA 95201 ,i IFEE Iv AMOUNT DUE AMOUNT REMITTED CK 9 CASH RECEIVED BY DATE Pf'RMiT'N0. s ��IVVV i i 24{REV. i K 51 ( �� y CS� %26 P IV