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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION „�� •" P O BOX 2009; STOCgTON, CA 95201 (209) 468-3447 { IRES I Y$AR FROM DATE ISk= (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 in made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health),y ►• Air'e r Job Address OdI" rfCity 0 Lot Size/Acreage ��°X _ � �,y f/J `1�J�GKt'N�r t--P Address 3 � �_t " ` 1�� Phone �Z"�z` i Owner's Name Pa p ,�] �^'I�,_p �lv u Y� 6 Phone .3�8 Contractor. �Gt ATO1i C • J HIR-- Address -�License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑'" ,DESTRUCTION :Out of Service well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR Cl+ OTHER Monitoring Well �Z ,N�a i %DISTANCE TO NEAREST: SEPTIC TANKt SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATIONS AGRICULTURE WELL OTHER WELL 1 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS d n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private C6 Gravel Peck ❑ Tracy Type of Casing Specifications 1 �} M Public I:1 Other 0 Delta Depth of Grout Seal Type of Grout 1 13�1 C3 Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by 1� Repair Work Done L3 Type of Pump 1, H.P. /�• State Work Dona _��L O� L U ` Well Destruction ❑ Well Diameter sealing Material& Depth a P.0a } h4, Depth Filler Material & Depth k TYPE OF SEPTIC WORK: NEW INSTALLATION L REPAIR/ADDITION L-1 DESTRUCTION 0 INo septic system permitted if public Sewer is 4E available within 200 feet.) installation will serve: Residence_ !Commercial— Other V s Number of living units: Number of bedrooms; l J � - � Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg J Capacity No. Compartments PKG, TREATMENT PLT. 0 Method of Disposal 10 Distance to nearest: Well Foundation. Property Line! -S. Total len th/size I J� LEACHING LINE ❑ No. & Length of lines 9 FILTER BED ❑ Distance to nearest: Well Foundation Property Line ; SEEPAGE-PITS 11 Depth . Size Number = SUMPS CI Distance to nearest: Well Foundation Property Line ` DISPOSAL PONDS-- O-�,:�.,.,.. " ^. •.."".` _. . 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 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 perlormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicaypust ca for all required inspo'clighs. Complete drawing on reverse side: . / q Signed Title: 0h'7132 cJ! Y -- -.— Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Z - Pit or Grout Inspection by to Final Inspection by.,�� I _.— Date i f .I Additional Comments: er ` Applicant - Heturn all copies to. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES `445 N SAN JOAQUIN, P 0 BOX 2009, 3TOCKTON, CA 95201 .2�/t 2 FEE AMOUNT DUE { AMOUNT REMITTED LASH RECEIVED BY DATE PERM17'NO. INFO - . EH 13-24 tREV,1 i 4 51r _ �,O, ; EH'4 o 26 �p V