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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES a ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 ZMIT ESPIRES 1 YEAR FR-OW-DATE ISSUED (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 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. f Job Address 'S-2_-5:, -5-_ 4u , V _ _ Citfmk Lot Size/Acreage 1 tom. el C- L � c Owner's Name4 d _° Ute- ,\ Address 11 bin T Cj �� l?li+i•S1�riC X-P- Phone Z 51 .f Contract r h Address c�1s 7 O4{ License No, ��'o� Phon TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT C] DESTRUCTION ❑ Out of Service well Gl PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER 0 Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK _1/942_ SEWER LINES DISPOSAL FLD. PROP. LINE a FOUNDATION j AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r In atrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Do Private L1,Grival Pack n Tracy Type of Casing - Specifications-� " rblic 11 Other ❑ Datta Depth of Grout sal r Type of G outAc-4, Cl Irrigation Approx, Depth ❑ Eastern Surface Seal Inst ray Repair Work Done U Type of Pump L__ H.P.c:=)- State Work Done _ Ch Well Destruction ❑ Well Diameter Sealing Material i Depth Depth hiller Material i Depth TYPE OF SEPTIC WORK: NEWINSTALLATION❑ REPAIRIADOITION 0 DESTRUCTION CI (No septic system permitted if public sewer is Installation will serve: Residence— Commercial— Other available within 200 feet.l ` Number of living units: Number of bedrooms G Character of soil to a depth of 3 feet: Water.table depth SEPTIC TANK. ❑ Type/Mfg Capacity No..Compartments PKG, TREATMENT PLT. C7Meihod of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED (a Distance to nearest: Well Foundation Property Line p� SEEPAGE PITS 11 Depth Sire" t "� Number SUMPS LI Distance to nearest: Well Foundation Property Line k1 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 t rules and regulations of the San Joaquin County _ Home owner or licensed agent's signature certifies the,following: of the wor ollowing: "I certify that In the performance k-for which this permit is issued, I shall not ,,,,___!mploy any person in such manner as to become s66jo6t to worlrmen's compensation laws of'Californii." Contractor's hiring or sub-contracting signature g certifies the following; "I cenify that in the performance of the work for which this permit js issued, I shall employ persons subject to workman's compensa- tion laws of Cnllfornle." The applicant Myst call foy rral quit inspections; Complete drawing on reverse side. Signs `Title:,-- � _ '- Date: FOR DEPARTMENT USE ONLY-----_-,- Application NLY--^---„-„„,,,-Application Accepted by Date . _ L `Area- - Pit or Grout Inspection by Date-V—lVlql Final Inspection by __ Data Additional Comments: G Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES \( ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEE INFO AMOUNT DUE AMOUNT tiEMfTTED CK f CASH RECEWED BY DATE PERM17'NO, G}j . EH 13.71IREV. OA ��KSi p +/ EH 7426l-