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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLiC VICES ENVIRONHBNTAL HTALTH D VI ' 445 N SAN JOAQUIN, PHO NP (2 9,}3420 P O BOX 2009, STOCKTON, PFJWIT =IUS 3. YEAR FROM (Complete in Triplic tof)t�►/ a Application is hereby made to San Joaquin County for a permit to construct d/tM'Yns a Is application is made in compliance with San Joaquin County Ordinance No. 549 the Rules'and Regulations of-San i Joaquin County Public Health Services. Job Address I City &Iarzz Lot Size/AcreageAgm fi Zn i Owner's Name Address 8a . Sn)flhmtj� CA �!Bone Contractor Address License No Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION I-) Out of Service well ❑ PUMP INSTALLATION C-1 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK ! SEWER LINES �� DISPOSAL FLD.�i� PROP. LINE )L=FOUNDATION 77 f��' AGRICULTURE WELL OTHER WELL PITS/SUMPS .�lg INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ind atrial ❑ Open Bottom 0 Manteca Dia. of Welt Excavation a " Dia. of Well Casing n Domestic/Private Ji�1'G44 PackTracy Type of Casing Specifications 1'1 Public n Other n Nita Depth of Grout Seal 1 Type of Grouts« a I I Irrigation Approx. Depth 14 Eastern Surface Seal-Instaued by li " -ZE�L, W S4/. 1 M Repair Work Done C Type of Pump H.P. State Work Done Well Destruction © Weft Diameter Sealing Material & Depth Depth Filler Material i Depth i I TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADOITION I I DESTRUCTION I I Mo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial T Other Number of living units: Number of bedrooms 0 Character of Boll to a depth of 3 feet: Water table depth i SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments 0 PKG. TREATMENT PLT,❑ Method of Disposal CL to nearest: Well Foundation Property Line I li LEACHING LINE ❑ No. 6 Length of lines Total length/site FILTER BED O Disunu to nearest: F u tion Pro � r�¢a party Line SEEPAGE PITS 11 Depth Sire Number SUMPS 1.1 Distance tonearest: _�,aGeundation Property Lina DISPOSAL PONDS ❑ Jul 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 regulatiora of the San Joaquin County Home 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 manner as to become subject to workman's compensation taws of California."Contractor's hiring or subcontracting signature certifies the fofbwing: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compenss- tion laws of California," The applicant must ty; ad ions. Complete drawing on reverse side. y Signed X Title: Date- 2--d-/Z23 FOR DEPARTMENT USE ONLY Application Accepted by Data Area Pit or Grout# rtspactltsn by Date Final Inspection by Date Z Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services / �Q Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stltn, GA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. is EN tYI1(REV.1/R 51 �U + �� / �-3 �� U EH I4.7a q