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APPLICATION FOR PERMIT c SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT EgP„j„RB,�,,.1MAR PROM DATE ISSUED (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 cmWliance with San Joaquin County Ordinance No. 549 and 1962 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address I �'�� City Lot Size/Acreage C Owner's Name' Address Phone Contract dres ' —y3Q Icense N � Pho ^� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT rl DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION E7 SYSTEM REPAIR Z�- � OTHER ❑ Monitoring Well U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Indus 1 ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public I'll Other ❑ Delta Depth of Grout Seat Type of Grout Cl Ifrigarion Approx, Depth ❑ Eastern "/ Surface Soul Installed by ��,�tq Repair Work Done 9----Type of Pump H.P. f� —= ___ State Work Done / 1:11 Well Destruction D Well Diameter Sealing Material i Depth Depth Filler'Noterial i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION 0 (No 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 r SEPTIC TANK ❑ Type/Mfg Capacity No. ments rn PKG. TREATMENT PLT..CI Mall �t� Distance to nearest. Well Foundation Propenyllme � LEACHING LINE 0 No. & Length of lines To%4�r ;r FILTER BED 1.1 Distance to nearest: Well Foundation v� Y-I//f (f1 SEEPAGE PITS I I Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line IS/QN !` 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 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 Iowa of California." The applicant dst t 1 fl required ii�spej:tions, Complete drawing on 41y erse side. Signed X 74� Title: l Date: FOR DEPARTMENT USE ONLY v2l� Application Accepted by Date 71WA Area Pit or Grout Inspection by Date Final Inspection by ata /3 Additional Comments: Applicant — Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL_HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O 200(3, STOCKTON. CA 85201 FEE INFO AMOUNT DUE A O'UrNT RE�IT�TED CK I IJ RECEIVED BY DATE PERMIT'NO.' . EM 13'241REV.I i A 5 1 / 4 �s � T� c}MV � '77 gq� ?2--Z &` EN;4•te C