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APPLICATION FOR PRRNIT P II SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 /fr` (209) 468-3447 r)RZ IT EXP RES 7 JEAR ?ROM DAIE 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 1962 and the Rules and Regulations of San Joaquin County Public Health Services. y , Job Address r City Lot size/Acreage Owner's Name ., Address / Phone /7 Contractor Ll enA Pho TYPE OF WELL/PUMP: NEW WELL ElWELL REPLACEMENT 0 DESTRUCTION LI Out of Service Well G7 PUMP INSTALLATION © SYSTEM REPAIR C1 ;,` OTHER ❑ Monitoring Well C7 I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL iFLD. PROP. LINE------ FOUNDATION �• `• ''AGRICULTURE WELL ` -OTHER WELL PITS/SUMPS moi- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca t Dia. of Well Excavation Dia. of Well Casing G r Specifications U Domestic/PrivateVi ❑ Gravel Pack, n Tracy Typo of Casing M Public [1 Other ❑ Delta Depth of Grout Seal Type of Grout ` Ci Irrigation �. Apprarr.IDepth 0Eastern Surface Seal Installed by t }ry I Repair WWk Done U i Type of Pump __—H.P. — State Work Done+_ r Well Destruction ❑ Well Diameter Sealing Material Depth '' ' ;I Depth Filler Material 1r Depth i � � TYPE OF SEPTIC WORK: NEW INSTALLATION JO REPAIRIADDITION CI DESTRUCTIONiNo septic system permitted if public sewer is ayailable.within.200 feet.l_ Installation will serve: Residence-/J Commercial Other t Number of living units:/_� Number of bedrooms 4 . Character of soil to a depth of 3 feet::f fi - Y Water table depth ' I l Capacity t SEPTIC TANK ❑ Type/Mfg Pa Y No. Compartments PKG.,TREATMENT PLT.0 Method of Disposal ; t aDistance to nearest: Well Foundation Property Line r � LEACHING LINE 0 No. & Length of lines 1 t Total length/size FILTER BED n Distance to nearest: Welh Foundation Property Line , SEEPAGE PITS I I Depth I Size l Number Ik SUMPS LI Distance to nearest; Wait Foundation F Property Line DISPOSAL PONDS ❑ I 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 Joaquiri7county a 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." q F � l The applicant must call for all required ins ctio Completed wing on'feverse side. Date: --3 Signed - - ; U.SE_OlYLY I Application Accepted by 2- Date Pit orGrout Inspection by r Date Final Inspection by _ °`r --- Date �U Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES E ENVI-RONMENTAL HEALTH,DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON. CA 85201 i IFEENFO' AMOUNT,DUE;I AMOUNT REMITTED CASH CKS RECEIVED BY DATE s PERMIT'NO, � q . t�t3.z„Rt�.I,MyI �[-�V� o lf7�a� r