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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 YEAR (Complete in Triplicate) Application is hereby mode to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address `� Gly t Size/Acreage s . Owner's Name Jim= C ,J Address Phone Contra ��V�ddres� � icertse TYPE OF WELL/PUMA: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Seryiee Well ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ Monitoring Well U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Indo 1 ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia, of Well Casing omastic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public Cl Other O Delta Depth of Grout Seal Type of Grout 0 Irfigation Approx. Depth ❑ Eastern Surface Seal Installed by -• Repair Work Done E? Type of Pump H.P. 6P-e-- State Work Done L`hf Well Destruction . D Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION C3 DESTRUCTION CI (No septic system permitted if public sewer is available within 200 feet.I Z Installation will serve: -'Residence^ Commercial Other a� C Number of living units: Number of bedrooms P YMENT Character of soil to a depth of 3 feet: Water tab SEPTIC TANK ❑ Type/Mfg Capacity-------- No. Comp PKG. TREATMENT PLT. Cl Method opsttevosa 4 1322 Distance to nearest: Well Foundation Property Linq N COUNTY WAIN JU LEACHING LINE ❑ No. 8 Length of lines Total length/si TH DIVISION FILTER BED 0 Distance to'nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS Ll Distance to nearest: Well r -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 laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I comity 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: "l certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion Iowa of California," The applics r all requiragun coons, Complete drawing on rev" ev side. / Sign Title: . Date: r � 2— FOR DEPARTMENT USE ONLY Application Accepted by , Date .? Area -;2,/P Pit or Grout Inspection by Date Final inspection by Data Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BO 2408, STOCKTON. CA 95201 FEE INFO �/AMODUNyT�DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. EM t3.24 iREV.iix6)Ire 7�"V /�.t/ 333�