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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PER![IT E%PTB95 1 YEAR 2RQX SATE 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 conpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address;,L 2 `() City Lot Size/Acreage Owner's Name L54t' L4-� Address �' '',`` -- Phone Contract Addre f A .B&-- LZZY�-2� �f License NOG:7 f ��= Phone TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well Cl PUMP INSTALLATION ❑ SYSTEM REPAIR `t% OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PtTS/SUMPS { INTENDED USE 7 TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Ind atrial* ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i Int Oomastic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public V1 Other -O.Delta Depth of Grout Seal Type of Grout CJ Imoalion /'�� Approx. Depth ❑ Eastern Surface Seal installed by Q 4 Repair Work Done 8" Type of Pump H.P. "` State Work Done o Welt Destruction ❑ Well Diameter Sealing Material & Depth �} Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION M DESTRUCTION 0 iNo septic system permitted if public sewer is Cir available within 200 feet.) Installation will serve: Residence T,. Commercial Other (p i 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. C} Method of Disposal Distance to nearest: Well Foundation Property Line - i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I I SEEPAGE PITS IJ Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby cenify that I have prepared this 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 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.mue II f N to uir pec4ions. Complete drawing on r verse side, _V J Signed .__.._._._ ✓``� Title: �" Date: �-_ FOR DEPARTMENT USE ONLY Application Accepted by Date ! Area �l Pit or Grout Inspection by Date Final Inspection byDate Additional Comments: II �r Applicant - Return all, copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES { ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 1 445 N SAN JOAQUIN, P O BOX 2409, STOCKTON, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMiTTEO CK RECEIVEO SY OATE PERMIT'NO. . EH r34;1.2{/IAEV. /MSM �� ar- H c.�� Qy/ 7 �`y T/+L Z .5Z v CJ t `��+ f .� I