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3' APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 4 PERMIT IRIS 1 YEAR FRQX PATE ISSUE i ' /Y £ A,�� (Complete in Triplicate) ©G s -- 030- C)(,:;,Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address a r t City L OA ► Lot Size/Acreage Owner's Name.4�mn,.J .",a (ou.4 Address $!n E^ ortr b r Phone %9-306(, Contractor s .�r`r.tivn + Address28'S -Si License Phone -C7?2_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT I- DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER JZ g„ }ho itgr ng well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD,-f-36 PROP. L1NE FOUNDATION AGRICULTURE WELL75 - OTHER WELL �-5 PITS/SUMPSJ-10 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i * Industrial O Open Bottom ❑ Manteca Dia. of Wel Excavation Dia. of Well Casing c� Domestic/Private ❑ Gravel Pack, ❑ Tracy Type of Casing Specifications M Public CI Other i ❑ Delta Depth of Grout Seal Type of Grout-CL*m CJ Irrigation ._._,.Approx. Depth ❑ Eastern Surface Seal installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material is Depth L�a Depth Piller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION 0 DESTRUCTION CI (No septic system permitted if public sewer is available within 200 feet.) installation will senre: Residence_'Commercial Other s Number of living units: Number of bedrooms 1 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. & length of lines Total length/size FILTER BED ❑ Distance to nearest: Weft Foundation Property Line SEEPAGE PITS I I Depth C Siie Number SUMPS Ll Distance to nearest: Well Foundation Property Line F. , DISPOSAL PONDS .❑ F 1 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 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 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 compenso. tion laws of California." The app)' nt 1 call for r fired inspectlnns, Ca late drawing r e :Ida. Signed _ Title: d l_5Date: 11'1 OR ARTME USE ONLY Application Accepted by r Date t -a"� t Area ~' Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: �� r " r Applicant - Return 0. 1 copies to: SAN JOAQUIN COUNTY PUBLIC HSALTH SERVICES ENIVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O SOX 2008, STOCKTON, CA 135201 INFO AMOUNT OUE AMOUNT REMtTTEp CASH RECEIVED 8Y DATE PERM1.1`1 . .