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APPLICATION FOR PERM I T f11 w SAN'JOAQUIN COUNTY PUBLIC HEALTH iRVICES ENVIRONMENTAL HEALTH DIVISION '? 445 -N-SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009,, STOCKTON, CA 95201 y PERMIT EXPIRE T1 EROM DATE S i 44 (Complete inTriplicate) 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 couplianee with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. q/ �� r��' 5L Job Address ?# r�� 14�G. _ ! City sIO Lot Siae/Acreage d-a ��0 1 Owner's Name /"�'� S� .Address �L Geyl�CPhone / j totem VOLE C �1__ r Contractor T-.uo zo- ��rh4,AddressU33 _ License No.sJ_'/g79CKrPho TYPE OF WELL/PUMP: ! NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ out of service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C] Ses�r THER Monitoring well C, DISTANCE TO NEAREST: SEPTIC TANK . SEWER LINES DISPOSAL FLO. PROP. LINE` r I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA 1:1 CONSTRUCTION SPECIFICATIONS 0 Industrial 0 Open Bottom _ ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C7 Domestic/Private ❑ Gravel Pack ❑ Tracy 'Type of Casing Specifications I'1 Public II Cl Other fl Delta '11.Depth of Grout Seal y�� Type of Grout I I Irrigation _iApprox. Depth I I Eastern Surface Seal installed by Repair Work Done U Type.Of Pump H.P. State Work Done, Well Destruction ❑ Wall'Diameter Sealing'Naterial & Depth Depth Tiller listerlsl i Depth :z TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/AODITiON I 1 DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.1 Installation will serve: Residence— Commercial_ Other j� Number of living units.,' 4 Number of bedrooms Character of sod to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. L) Method of Disposal Distance to nearest: Well Foundation Property Line A i . LEACHING LINE CI No. b Length of lines I' i Total tengih/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1.1 Depth Size 1i Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 'R Ih ii 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 .1i 41 Home owner or licensed egent's�' gnsture certifies the following: "I certify that 4n the performance of the work for which this permit is issued, 1 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 shad employ persons subject to workman's compensa- tion laws of California.' :I, r The applicant at tali for all r1f l ' pections. Complete drawing on reverse side, u II r r Signed Title: r S Date: t FOR DEPARTMENT USE ONLY �j �} Application Accepted by "-'+ _,.. 1 ~--- Date _ 1�� Area 5y Ph or Grout Inspection by Date ,Final Inspection by ;Date Additional Comments: f Applicant - Return all copies to: San Joaquin County Public Health'Services i Environmental Health Permit/Services g9 446 H-San Joaquin, P 0 Box 2009, Stkn, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED " CASH CK 0 RECEIVED BY DATE PERMIT'NO. . EKM24rIIEV.1iR51 �.. �� F -4036 1V�..I•�t ��.� (,!6 .. EH 14.20 1 \ II _