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APPLICATION FOR PERMIT '_ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES; -` EffVIRONI�ENTAL HEALTH DIVISION • f Ii -- 445 N SAN JOAQUIN, PHONE (209)468-3420 : a P O. BO% 2009, STOCKTON, CA 95201 5.4 - PMIT #FSPIRES 1 FROM D TE S (-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 vlth San Joaquin County Ordinance No. 549 and 1862 and the Rifles and Regulations of,Sdn Joaquin County Public Health Services. .'' ` a . i ' Q City S�d Lot Sine/Acreage Job Address Address f — Phone Owner's Name _ ..� -- - - - - _ ._ . 60 Phone 4 Contractor2 I�E !! Address C..s.c��T �� _ L'+cense No. TYPE OF WELUPLIMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ OTHER ❑ Monitoring well ❑ PUMP INSTALLA ION ❑ SYSTEM REPAIR ❑ $,v + i DISTANCE TO NEAREST: SEPTIC TANK �0 JL �. SEWER LINES DISPOSAL FLD: PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS IN USE TYPE-OF'WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O __ Dia. of Well Casing C7 Industrial j Open Bottom ❑ Manteca Dia. of Well Excavation 7 Type of Casing << Specifications C`1 Dornestic/Private ❑ Gravel Pack ❑ Tracy T of Grout [ 1 P blit Cl Other Cl Delta Depth of Grout Seal �r Approx..Depth l I Eastern Surface Seal Installed by �/) i " Y ----- __ State Work Done v I �Repoir Work Done U Type of Pump H.P. II - �' Sealing Material C-Depth. Wa11 Destruction. D , Well.-Disrneter. -- f7 Killer Material i Depth Depth TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIRIADDITION I-L-DESTRUCTION I 1 available within 200 feet.) public sewer is F Installation will�sdm: Residence Commercial +Other " P i _ Number of living u ' Number of bedrooms '� a depth µ Clutracter of soil to if clop. _ t:. L I ❑TypelMig Capacity No. Campsr;msnts� }. SEPTIC TANK +:- PKG:TREATMENT PLT.Ci i Method of pisposal ~` t Property Line, D'grtance to nearest:.— Wetl Foundation oPe Y - w r° LEACHING LINE! L1 No. b Length a-_- n TotahSengthlsi2e „ FILTER BED II!! ❑ Dist o nearest Well Foundation Property Lina SEEPAGE PrOND�S 1 1 Depth Size Number ?" Property Line .SUMPS LI Distance to nearest: Well Foundation DISPOSAL ❑ j .1-horeby certify that I have prepared this application and that the work wiH be done in accordance with San Joaquin county ordinances, state laws, and rubs and regulations of the San Joaquin County Hort+a 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`all not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's.hiring or sub contractinggnature " eertilies 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-: 41 tion laws of California." The applicant et call for MI r ins a. Complete drawing on reverse side. ,. Ina: Date: 2—Ll Signed ;. OR DEPARTMENT USE ONLY Data .—t- — Area 2 l 'Application Accepted by - - ' �l Date f Final Inspection by Date Pit oGrout I spection by :Additional Comments : ' /Z 1 !�� k1 Applicant - Return all copies to: San Joaqui County Public Health Services iiI i Snvironmen al Health Permit/Services �l 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 ; C FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DAT PERMIT'NO. INFOgf 4 . EH 13.24(ItEV•I/X,6) IW V' EH 14-26 - - '