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• APPLICATION FOR PERMIT SAN JOAQUIN COUWJrY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PMIT EXPIRES I YEAR FROM DATE SU (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 with San Joaquin County Ordinance no. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. `10 7 �' Lot 'i /Acreage Job Address City Lot S ` Owner's Name 73` e Address l Phone ! Contract �+�1 I r AddressJig JEU, License No(v10-1 �_Phones"/ TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT n DESTRUCTION Cl Out Monitoring Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ n DISTANCE TO NEAREST: SEPTIC TANK[(W-�� SEWER LINES l DISPOSAL FLD. PROP. LINE FOUNDATION.<6=--- AGRICULTURE WELL V6 2 OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LI industrial ❑ Open Bottom EIManteci Dia. of Well Excavation Dia. of Well Casing ,cloomestic/Private oRGravel Pack ❑ Tracy Type of Casing— , iy Specifications r r- Il Public 171 Other fl Delta Depth of Grout Seal B T of Grout +e't• 1 I Irrigation Z ��Approx. Depth I I Eastern Surface Seal Installed Hy ��,1AP - - Repair Work Done L1 Type of Pump H.P. State Work Done We" Destruction ❑ Well Diameter Sealing Material 4 Depth t.,4 Depth Filler Material i Depth TYPE OF SEPTICWORK? NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feat.) r , Installation will serve: Residence— Commercial T Other {r) Number of living units: Number of bedrooms Character of Boll to a depth of 3 feat: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT.0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines Total length/size rn FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 v SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that 1 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 Sen 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 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 shall employ persons subject to workman's compensa- tion laws of California." The applicant pwst call for all required inspections. Complete drawing on reverse ifide.gigue r Title: Date: ^�—�� FOR DEPARTMENT USE ONLY Application Accepted by Data o-)L _ 3 Area D Pit or t" it Inspection by Dat 'Z iG1Final Inspection by 1F 4�i Data Additional Comments: Applicant - Return all copies to: San Joaquin County public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH a FM1l24tI1Ev.r/SSI �,�- F r�6 Els 11.7a