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APPLICATION FOR PBR1dIT � SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES r t ENVIRONMENTAL HEALTH DIVISION I P O BOX 2009, STOCKTON, CA 95201 . . ...... -� (209) 468-3447 YEAR PROM DATE ISSUBP (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 with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health services. ' Job Address `j `ice Sam d City %zee/Acreage n ac Gl kNoma 'b Address S� trnn �"�><e � Phone ' �� 7 Owner's i- p GI 3 S3 Contractor _y r k Address d License No,cPhone �' 7 E I TYPE OF WELL/PUMP. NE WELL WELL REPLACEMENT f7 DESTRUCTION L] Out of service Well ❑ PUMP INSTALLATION SYSTEM REPAIR 0 OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANKbO SEWER LINES DISPOSAL FLO. PROP. LINE j FOUNDATION AGRICULTURE WELL,�Q OTHER WELL PITS/SUMPS 1 I I } INTENDED USE TYPE OF,WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS M Industrial Open Bottom ❑ Manteca Ois_ol Well=Excavation Dia. of Well Casing ' Domestic/Private Gravel Pack L7 TyType of Casing Specifications / �. ` 4 Xr Q Q Public ("ll Other �ll�` D Delta' Depth of Grout�SeaEX Type of Grout rt h M lrhoauon 30c Appro�, Depth EDEastern Surface Sou"I:Installed by Repair Work Done 0--''Typo of Pump �� H.'P: State Work Done_ r` Well Dos lion 0 Well Diameter Sealing Material i Depth 3r f . '` Depth «# 'Filler Material i Depth k 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 teal: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments I i PKG. TREATMENT PLT. Cl ' i t! Method of Disposal Distance to nearest: Well Foundation Property Line I s Ji � LEACHING LINE L-1 No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS 11 Depth SUMPS LI Distance to nearest: Well Foundation ^� Property Line Q� '4 -0---- 'r-- I hereby cenify that I have prepared this application and that lhe-w`ork will be done in-accordance with San Joaquin county ordinances, state laws, and l 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, t shall employ persons subject to workman's compensa- tlon laws of California." I r r The applicant must tail for all req�uiid inspectioni..,Complete drawing on reverse side. Signe ,x Aln� 1'l;Q�tit�t_A Title: G /V tc- t' e _5_ _ ._ Date: R DEPARTMENT USE ONLY 5 Application Accepted by Date. Area Pit or Grout Inspection by Date U Lblck k Final Inspection by D(V\ Date—2 Additional Comments: C !G ! p Applicant - Return all 0Op1ee to,t SAN JOAQ IN COU0rY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 ! SAN_JOAQtIktl P O SOX 2008,_STUCKTON,�CA-85201 FEEMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATEPERMIT'NO. INF CASH . EH 13-I4 34.6�' EH,lob