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APPLICATION FOR PERMIT P SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201Ili� � (209) 468-3447 p SAN 1991 PERMIT EXPIRES I YEAR PROM DATEfNVj�N41r/1 SerUNTY (Complete in Triplicate) r4t'yC-4C] '�I�j�Es Application is hereby alade,to San Joaquin County for a permit to construct and/or install the work herein descr bed� �S/�,ts application is made in conpliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health services. c��(� _ l!}-PN a��- is a -o q Job Address . (>?_. !. _ p f�C (��rft-�f f (��-U 1� ,�_. City Lot Size/Acreage � I �'f , _ ^, Owner's Name r'�VILICf,t!D L I�tiJc`SrhtEn'T CC) Address �, ��c S�°� � L/1T111� .�1J� _ Phone G Contractors 7 a�Q Ad dies s,2FZS cr< r License No:�/ZZ&5 Phone z TYPE OF WELL/PUMP: NEW WELL I$' WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well Ek DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 501 DISPOSAL FLD. PROP. LINE : FOUNDATION 20 AGRICULTURE WELL OTHER WELL PITS/SUMPS 5' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS_ f fl industrial O Open Bottom I'X Manteca Dia. of Well Excavation f ��' Dia. of Well Casing r W Domestic/Private CKGrayel Pack 0 Tracy Type of Casing_20,0 _ Specifications 'TCW ¢0 M Public i-1 Other ❑ Delta Depth of Grout Seal Sr112fACE Type of Grout M Irrioation .3,Approx. Depth ❑ Eastern Surface Sedl Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Welt Destruction 0 Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION ZI DESTRUCTION M (No septic system permitted if public sewer is �f available within 200 feet.] Installation will serve: Residence_„ Commercial— Other Number of living units: Number of bedrooms Character of soli to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No. $ Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS D 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: "t 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 laws of California." The applican ust all for a I r q ired ' pec ions. Complete drawing on reverse side. Signed Title: (f0A-)S'ut-1,4 0! Date: . r,�,-7 /9F FOR DEPARTMENT USE ONLY Application Accepted by Dated Area 4 2 U C C Pit or Grout Inspection by Date Final Inspection by _277 Data �4 G Additional Comments. '"1 UJ Applicant – Return all copies to: SAN JOAQUINCOUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 85201 FEE INFO AMOUNT DUE AMOUNT fiEMiTTED pCK if �ASSH RECEIVED BY L� DATE PERMIT'No. . E 13,24{REV.Irw51 ER i4•i0