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APPLICATION FOR PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SEKVSLL <br />ENVIRONMENTAL HEALTH DIVISION ��tt <br />P 0 BOX 2009, STOCKTON, CA 9520+AID <br />(209) 468-3447 — <br />PERMIT EXPIRES 1 YEAR PROM DATES IE 35 UED <br />(Complete in Triplicate) <br />Application is hereby mads to San Joaquin County for aj <br />application is made in compliance vith n Joaquin CountyrOrdinancemit to nNo. 549struct aand o1862sand theta <br />eRule& and�Regulations�of Sane <br />SaJ <br />Joaquin County Public Health Services. 1' <br />Is7lo o�,v7)2� ATN IZ3 - r9/ -Q r <br />Job Address C <br />- 1 CLUti I) tQ i U 6 City STrx k:�7b/J Lot Size/Acreage r l Z 'Ac-, <br />Ownar's Name /' 4ruoeL !u.,,f y c Z Address 1033 W. W AuN,, II S I ��. -rot.) Phone 464 - I- I <br />Contractor) C,( aror% AddressZU t./�Y it~ ST6(-<-101J License No.s/Z%_ Phone <br />TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT n DESTRUCTION 0 Out of Seryice Well ❑ <br />PUMP INSTALLATION O SYSTEM REPAIR Cl OTHER O Monitoring Well <br />DISTANCE TO NEAREST: SEPTIC TANK ,L_ SEWER LINES2� r' //_ DISPOSAL FLD. N/,4 PROP. LINE �� <br />FOUNDATION ZO AGRICULTURE WELL d/1 OTHER WELL_ PITS/SUMPS A///A <br />INTENDED USE <br />0 Industrial <br />U Domestic/Private <br />Public <br />MON i roiZi 1v <br />IrriUation <br />Repair Work Done U <br />Well Destruction O <br />YPE OF SEPTIC WOR <br />TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />O Open Bottom O Manteca Dia. of Well Excavation r Dia. of Well Casing <br />0 Gravel Pack O Tracy Type of Casing. Py�-- Specifications f6H 40 <br />('I Other O Delta Depth of Grout Seal 'S Type of Grout_CEibEiv� <br />A Approx. Depth ❑ Eastern Surfice Soul Installed by _CoaJr2/aCToa- <br />Type of Pump H. P. State Work Done _ <br />Well Diameter Sealing Material i Depth <br />Depth Piller Material i Depth <br />NEW INSTALLATION <br />REPAIR/ADDITION 'MDESTRUCTION <br />Installation will serve: Residence _, Commercial _ Other <br />(No septic system permitted if public sower Is <br />available within 200 feet.) <br />Number of living units: Number of bedrooms <br />Character of soil to a depth of 3 feet: <br />Water table depth _ <br />SEPTIC TANK O Type/Mfg Capacity_ <br />PKG. TREATMENT PLT, 0 No. Compartments <br />Method of Disposal <br />Distance to nearest: Well Foundation Progeny Line <br />LEACHING LINE 0 No. & Length of lines <br />FILTER BED n Distance to nearest: <br />Total length/size_ <br />Well Foundation Property Line <br />SEEPAGE PITS I I Depth Sire <br />_ Number <br />SUMPS LI Distance to nearest: Well Foundation <br />DISPOSAL PONDS Q property Line <br />41 <br />I hereby sonify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />rules and regulations of the San Joaquin County county ordinances, ;tato laws, and <br />Home owner Or licensed agent's signature certifies the following: "I certify that In the performance of the work for which jt.' is issued, I shall not <br />employ any parson in such manner as to become subject to workman's compensation laws of California." Contractor's�s`ulwg <br />certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ per ratting signature <br />tion laws of California," ansa. <br />The applican tra cal all requi ed Ins ,ctions, Complete drawing on reverse side. <br />Q , <br />Signed Title: <br />DEPARTMENT USE ONLY <br />Application Accepted by <br />Date <br />Pit or Grout Inspection Dy Date Final Inspection by <br />Additional Comments: 19L, <br />Applicant - Return all copies to: <br />13.21 UEV. Iiny <br />to 20 <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENV44IRONMENTAL N HEALTH DIVISION <br />SAN JOAQUIN,P OBOXE <br />2009, <br />5STOCKTOM, CA 95201 <br />Date /D —!&s <br />