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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOC TON; CA 95201 EXPIRES 1 YEAR FROM DATE ISSMIM (Complete in Triplicate) Application It hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This application is made iit compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address /, ,Sss- kr'• ro" +� City Lot Site/Acreage Owner's Name 14MIO�MAyI _. :/"4address Phone i4 cS'7 I! �7 Contractor C� /! Address License No.4�--Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLAC--MENT ❑ DESTRUCTION L} Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER M torifngl�Wn;ll C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. `PRO LINE rU FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS S 1 Y 60 r'1 HQ Cl industrial C1 Open Bottom ❑ Manteca Pis. of Well Excavation Dia. of Well Casing �" V IJ DomasI /Private [] Gravel Pack LITTracy Type of Ca Ing _ Specifications y qI Public ,#Uy her 1� Delta Depth of Grout Seal S Type of Grout a+ 1I Irrigate n " �[Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. Sipte Vyork pone --�—Well Destruction ❑ Well Diameter Sealing Material Ill Depth Depth Filler Material & Depth it TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION i I 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 soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well roundati n Property Line LEACHING LINE Cl No. & Length of lines _ Total lengthtsize_ 'i FiLTER BED Cl Distance to nearest: Well Foundation Property Lane SEEPAGE PITS 11 Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 t e performance of the work for which this permit is issued, I shell 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 must call for all required Inspections. Complete drawing on reverse side, Signed X___-9:5L s _� Title: #;4ZZDate:17 FOR DEPARTMENT USE ONLY Application Accepted by o` Area Pit or Grout Inspection by n / Date 3 � Fina Inspection by ��-[� Date 6 / Additional Comments: bd/l rl e- i►1 LtJ p Applicant - Return all copies to: San Joaquin Coun y Public Health Services, Environmental Health P rmit/Serviceti 1601 E. Hazeltan Ave:, P 0 Box 2009. Stockton, CA 95201 INFO AMOUNT DUE yA,fpMODUNT REMITTED CK CASH RECEIVED BY DATE PERMI7'NO. EH 19.24 f11Ev.I f R 5 1 �� 91-3 77 `