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APPLICATION FOR PERMIT f SAN 'JOAQUIN� COUNTY PUBLIC HEALTH SERVICES -ENVNQO4lENTAL HEALTH DIVISION P O BO% 2009, STOWON, CA 95201 (209) 468-3447 YEAR fRQX DATE ISSUED (Complete in Triplicate) Application is hereby made.to San'oaquia County for a permit to construct and/or install the +cork herein described. This application is made in compliancIa vith ,8an Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 'L ?, City Lot Size/Acreage Job Address J I N •d, 3W3 G Address �r Phone _ Owner's N.,,.. - - �_ - .,4-- �----�_.--_ _. __380 t9V6 ot---SST C �n� r PLO(LICDi Address — ALL IZ& CA License No.:V(d1P�eY' Z�`6� (� ractor� � of Service Well 0 TYPE OF WELLIPUMP: NEW WELL- ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ out monitoring Well E PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ � OTHER❑ IQ r�0 r �^ _�''70 PROP. LINE " DISTANCE TO NEAREST: SEPTIC TANK_ SEWER LINES DISPOSAL F,LD:� _ �' P.IT5151}MPS�f FOUNDATION _L-.�...- AGRICULTURE WELL OTHER WELL . k INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ;,°`` ''' Z If r Ill Industrial 0 Open 9ottom-" O nteca MaDla. of Well Excavation ` — Type of Casing UG Specifications U Domestic lPrivate ❑ Gravel Pack ❑ Tracy . . .. p Public QF{?tt+er © Delta ^'Depth of-Grout Seale ` Type o} Grout i CI trriUation (!�eApprox' Depth d Eastern Surfaee.Seul installed by Repait Work Done L) . Type of Pump H.P. 'St to Work Doner Well Dest�action ❑ Well Diameter Sealing Material 4 ee± th Sof M7dry hi Depth ► f Filler Material 4 Depth TYPE—0F. SEPTIC WORK:' NEW INSTALLATION ❑ REPAIR/XDOITI(N C OESTRUG ION 0 INo'septic system permitted if public sewer is f available within 20011 feet,) Installation will "No: Residence Commercial— 'Other' Number of living units: umber of bedrooms t Ufa � � ' ' • '` I Character of soil to a depth of 31=1 � Water table depth SEPTIC TANK. ❑ Type/Mfg acity No. Compartments PKG, TREATMENT PLT. ❑ f _ Method of Disposal I ..t/ 1 Distance to nearest: Well undation Propay Lihe ?,r— - LEACHING LINE ❑ No. 8 Length of lines Total length/size Distance to nearest: Well Foundation Property Line t `_ FILTER BED [f t 'si-• ti SEEPAGE PITS 11 Depth S' Numbs SUMPS LI Distance to nearest: ell Foundation Props Line DISPOSAL PONDS CI I hereby certify that l'heve 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: "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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant mu call for all re 'red 'nspgctions. Complete drawing on reverse side. �U -24,46 5ignsd Title: . -• .'� Date: Sri FOR DEPARTMENT USE ONLY '1 , , � � Area Application Accepted by i "'�' Data i- h � Pit or Grout inspection bA. Date y Date Final Inspection b Additional Comments. jv Applicant - Return all copies to: SATE JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK ICASH RECEIVED BY DATE PERMIT NO. INFO (j /�/�] n ( . EH 11.24 Otty,I/its 1 /f r V+j V (r C.Y C��/ I� ' 7 F EH 14.2e V0