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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 i (Complete in Triplicate) Y-- Application is hereby made,to San Joaquin County fora permit to construct and/or install the work herein This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and thtA%tA.w► d� Of San Joaquin County Public Health Services. d �n p�R,vii t 1 SE Job Address Z9 /V, (ff� wgg City Lot Size/Acreage Owner's Name 5#117111 1 OD Address �• "" Phone l Contractor ��' Lam' Address License No. a Phone Le TYPE OF WELLIPUMP: NEW WELL © WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Nell D PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER� Monitoring Well C7 SrEs7-�n�C.JGS DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. RR=-W4E FOUNDATION AGRICULTURE WELL OTHER WELL Pf87St7f4tP5 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , 1.1 Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia, of Well Casing U Domestic/Private ❑ Gravel Peck ❑ Tracy Type of Casing _Specifications ❑ Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout CI Irrigation Approx. Depth D Eastern Surface Seal Insta)Ind by An>TIGi>7�r' -7/LV lrVi Repair Work Dona U Type of Pump H.P. State Work Done ��af W cLi-P, Well Destruction 0 Well Diameter Sealing Material i Depth _ l C r;.&0 C-�ICort-e! Depth Filler Naterial i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIRIADDITION 0 DESTRUCTION .CI (No septic system permitted if public sewer is available within 200 feet.) C 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 SEPTIC TANK 0 Type/Mfg - Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal r Distance to nearest: Well Foundation Property Line f. LEACHING LINE C1 No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line 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 lInot fff 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 employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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 cotion laws of California." ' The applicant must ca for all re* ira�spections, omplete drawing on reverse side. / Signed Title: `.. �_LU/V L9�^ Date: 15 /17-14?l FOR DEPARTMENT USE ONLY Application Accepted by Date «r )3 Area Pit or Grout Inspection by Date Final Inspection by Date 0"+-r7& Tb a2w- . r Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES ® P 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMiT7Ep CASH RECEIVED BY DATE PERM11'NO. + EH 13-24 1REV.I/M5 EH:a•� l✓L /��