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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 S IT EMIR& 1 YEAR1?ROld DATE,3SSUED (Complete in Triplicate) Application In hereby made,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 -ai-44-le-t,Ls __.._ City A42PI �. r Lot Size/Acreage Owner's Name Address _ (- Q ,(,j f7�C 5—/606105�: hone on Contractor il-A 4Address_ � I r License No. � r�-I�S`e�±Phone TYPE OF WELL/PUMP. NEW WELL WELL REPLACEMENT DESTRUCTION C1 Out of Service Well ❑ PUMP INSTALLATION ❑� SYSTEM REPAIR OTHJR ❑ Monitorings Well [3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. IkJ2 PROP. LINE _ !J FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION'S nJr,dustrial ❑Dpen Bottom ItiAanteca Dia. of Well Exc atjpn Dia. of Well Ca Domestic/Private )d-,Gravel Pack 0 Tracy Type of Casing c- Specifications sin dr J� p Public 171 Other ❑ Delta Depth of Grout Seal yy Type of Grout EUX3 t r� CJ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by-- _-rf 1S,!►� � ,,, Repair Work Done U Type of Pump H.P, State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION M DESTRUCTION M lNo septic system permitted if public sewer is available within 200 feet.} Installation will serve: Residence— Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L1 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well 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 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 persona subject to workman's compensa- tion laws of California." The applicant t all fqF all req r insPections, Complete drawing on r rse side, �^ Signed X. Title: _ -- _._._ Date: FOR DEPARTMENT USE ONLY Application Accepted by DateArea .� Pit or rout In ction b -7 Date 1 Final Inspection by Date Additional Comments: Applica�nty- Return all copies'7to: S14 AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES cA o ! 445INOSAN JOAQUIN,NMENTAL TP 0 BOX2009,,DIVISION PERMIT/SERVICES CA 85201 N C ( r INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT IVO. va R7 Y�' 0o furl . em A-24 IREV.i is 51 t.7 1 3 EN'42e