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.� APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 •+*+Au*�^ ��[pIRES 1 YEAR FROM DATE ISSUE (Complete in Triplicate) Application In 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 �Go TTj � City G ' Lot size/Acreage ,r7-,A-d Aux . Z13 6 Owner's Namo Address 1- ro ' C .4 `�00 f 0 Phone — 36G3 07ngS C- ej A e A.,6 5yo'rr Contractor �� die i�6' Address &,X--&0 License No. s/F-� 2 8 Phone 3> ' ?S*C TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ®30/,L p�>�W�11 O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial O Open Bottom O Manteca Oia. of.WKExcavation 8 Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout C Irrigation _ Approx. Depth C3 Eastern Surface Seal Installed by Repair Work Done U Typo of Pump H.P. State Work Done _ Well Destruction O Wall Diameter — Sealing Material i Depth Depth 5/5 I-1e7- Tiller Material i Depth � TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION 0 DESTRUCTION G INo septic system permitted it public sewer is available within 200 fest.! cl�; Installation will serve: Residence_ Commercial— Other �,; Number of living units: Number of bedrooms l/�' Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line r !� LEACHING LINE ❑ No. b Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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 subcontracting 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 us 11 for all a ired inspac ' ns. mplete drawing on rever a side. Signe Title Date: FOR DEPAWMIENT USE ONLY C/ `l// Application Accepted by Data) Area r C Pit or Grout Inspection by Date �ZFinal Inspection by Deto Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE INFO AMOOUNT/DUE AMOUNT REMITTED 7�CK RECEIVED BY . DATE PERMITTNO. EH A-M EH 13.24IIIEV. C/ �r