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APPLICATION FOR PERMIT 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 EZPIRES 1 YEAR FROM DATE SU (Complete in Triplicate) Application in hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in ccuPliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. e XJob Address l l L 0A \ �,� City �'+�y Lot Size/Acreage 54wner's Name_IIM4� ` Address _ 12� 1C-..UJJ i IJ r14lu Phone Cnz, l " ContractorAddress License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ MonitoringWell ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE ! FOUNDATIONS AGRICULTURE WELL ' "OTHER WELL PITS/SUMPS _ iNTENDED'USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial's ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private p Gravel Pack ❑ Tracy Type of Casing Specifications 1'1 Public, t fa Other Fl Delta Depth of Grout Seal Type of Grout 1 , Irrinalion —Approx. Depth l I Eastern Surface Seal Installed by 1 Repair Work Done X13 Type of Pump H,P. State Work Done_ 1 Well Destruction ❑ Well Diameter Sealing Material i Depth Depth 11`111er Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION.1 1 i DESTRUCTIONavailable within 200 feet.)(NO septic system permitted if public sewer is } i Installation will serve: Residence___._ Commercial_ Other Number of living units: Number of bedrooms , Character of SON to a depth of 3 fast: Water table depth r SEPTIC TANK ❑ Typo/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Property Line SEEPAGE PITS 11 - Depth Sire Number SUMPS LI .Distance to nearest: Well Foundation Property Lino 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, stats 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 10 become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the folbwing: "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 Callfornia." _ �i The applicant must call for all required int - tions. Complete drawing onreverseside, r -w- Signed X Titter�' �T t�� ' Q �- A I Date: FO EPARTMENT USE ONLY Application Accepted by Date �9�Z�Area f Pk Or Grr ui Inspection by Data Final Inspection by S-1. Date r G K F ems° Additional Comments: G 9�e 5R Applicant -Return all copies to: San Joaquin County public Health Services Env445 N San Joaquin, Health Permit/Services 445 N San Joaquin, P 'O Boa 2069, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY RE INFO CASH DATE PERMIT'NO. . Ek 1744 IREV.iinsl . fH 14-Ea —3bo