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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES • ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 a PERMIT EXPIRES I YE FROM DATE- ISSUJED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services.' tt i Job Address 3788 Jr'� 1310" City Lot Size/Acreage a• t i Zoo- C-4---Ce...�a,ti Owner's Name fnoC0.� Ecr �or� Address S-r oo v CA 9y.Si Phone 7 - 2 1 811 Hwm;ltor. Ilven;.e, � Contractor Drrl�r+� v Address M �k L 9 02 L'f�e � e.3'ryr�z-phone yt �u-� ° i TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT.€? DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION a SYSTEM REPAIR C1OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES .rp ft- DISPOSAL FLD. �� PROP. LINE FOUNDATION � AGRICULTUAE WELL ' OTHER WELL PITS/SUMPS . . INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom G Manteca Dia. of Well Excavation $ iAcj►r` _ Dia, of Well Casing, ine-6e CI Domestic/Private Gravel Pack 'Tracy Type of Casing St1r.eA.,1g.9a pl/G Specifications ('I Public n Other 171 Delta Depth of Grout Seal '- Type of Grout _ I i Irrigation ;Approx. Depth I I Eastern- Surface Seal Installed by_ pgyt" t4*'-., 5+�� Repair Work Done U Type of Pump H.P. State Work Done_ ?� Weil Destruction ❑ Well Diameter Sealing Material i Depth Depth Piller Material i Depth �\ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/AD.DITION I I DESTRUCTION I I INo septic system permitted if public sewer is } available within 200 feet.) f Installation will serve: Residence— Commercial_,. Other Number of living units: Number of bedrooms Character of will to a depth of.3 feet: Water table depth U.} SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of.Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. 3 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Site Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application artd 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 subpa to workmen's compensation laws of California." Contractor's hiring or sub-contracting signature I 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 compenss- ! tion laws of Caiifornla ,L The applicant must call for all required inspections. Complete drawing on reverse side.. eQ4e, I Signed X .t.-rriJ Title: rot r.o �!S_� Date:V QF FOR DEPARTMENT USE ONLY Application Accepted byN`' � _ Date /{ Aroa Pit or Grout Inspection by Date Final Inspection by _ /.1 L/ '� Data Additional Comments: - Applicant - Return all copies to:', San Joaquin County Public Health Services Environmental Health Permit/Services 445 H San Joaquin, P 0 Box 2009, Stkn, CA 95201 r FEE AMOUNT DUE AMOUNT REMfTTED CK If RECEIVED BY DATE PERMIT NO. INFO CASH . EH 13.24 IREV.iresl �� EH 14.7E CJ