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r� APPLICATION FOR PERMIT `... SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby msde.to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance vlth San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. /J Job Address 3 �• o ?T-t IVOA _ Cit ' oefr• a Lot Size/Acreage n t!,?a�i Owner's Name �� Cy s Address 6-4 . 5ce7--s �G Y Phone Contractor A).k Address ��4rdcae GDl2�acJ�_ �4 License No. Phone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT O DESTRUCTION O Out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR O OTHER ( y6 Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 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 Dia. of)4W Excavation Dia. of Well Casing U Domestic/Private O Gravel Pack O Tracy Type of Casing Specifications C) Public 1:1 Other O Delta Depth of Grout Seal -� sigG Type of Grout CI 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 i Depth Depth S� �T filler Material 4 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION Cf DESTRUCTION U 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 acid to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments (�!� PKG. TREATMENT PLT.C1 Method of Disposal Distance to nearest: Well Foundation Property Line t7 LEACHING LINE O No. b Length of lines Total length/size a FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS II Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 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 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, t 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant ust II for all "fired inspec s. omplete drawing on?ENT side. Sign Till Date: �D FOR DEPA TUSE ONLY Application Accepted by ^"'� Date 5_/rf Area Pit or Grout Inspection by Date d Final Inspection by Data Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BGL 2009, STOCKTON, CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. . EH 14•24 111EV.,, 5) x, i l g9. LL..) EH;�•Zd