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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 R PBOU DATE ISSUED (Complete in Triplicate) Application Is hereby made to Saa oaqu n County for a Permit to construct and/or install the vork herein described. This application is made in coo-,fiance with San Joaquin County Ordinance No. 549 and 1862 and the Rules sad Regulations of San Joaquin County Public Health Sgrvices. f49,47-7- Off- &77-w4 i Job Address ME o�/NrERst-Ce ` AbA7Rp;s � AA C;ty STl-nl Lot Size/Acreage 4r- 7_47JI1— Luc ASS Cup • � _ S / gigL�ifll Owner's Name � o�4� Address &2, LO—ex 2 Phone Contracto _ �ik ! / X Address 1432S�,MtJr' o License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Monitrr/o/�ring Kell ri DISTANCE TO NEAREST; SEPTIC TANK ___ SEWER LINES DISPOSAL FLD. PROP. LINE 7 rST $Di2( CS FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �`tO 40, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (I Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing U Domestic/Private 0 Gravel Pack ❑ Tracy Type of Ca in r r Specifications M Public Cl Other 0 Delta Depth of�I TO 4a Type of Grout M Irrigation —,Approx. Depth ❑ Eastern Surface Seal Installed bjr Repair Work Done C] LTvm of Pump H.P. State.Work Dona Weil Destruction O tell Diameter Sealing Material i Depth CO"t `11Vv pth Filler Material i Depth TYPE OF SEPTIC WORD: NEW INSTALLATION L3 REPAIR IADDITION MDESTRUCTION Cl tNo septic system rmitted if public fewer is available within 200 eat.) 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 O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. '& Length of lines Total length/size FILTER BED 0 Distance to nearest. Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundstion Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepardrthis application and that the work wilt 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 perlormanCe 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 of sub-contracting 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 all for required ins coons. Complete drawing on reverse side. Signed Title: _ __. rte/ "�' 11Date: FOR EP MENT USE ONLY '� �n Application Accepted by01_ Date !� Area C� Pit or Grout Inspection by Date Final Inspection by Date / I Additional Comments: _ Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES `r' ' 445 N SAN JOAQUIN, P 0 Ba 009, STOCKTON, CA 135241FEE INFO AMOUNT DUE (AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT NO. IREV. �—' (J FH 14-MF'' e , 'tea