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"PLICATION FOR PERS{I T SAN JOAQUIN COUNTY PUBLIC', REALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT, fi'XATRRS 1 YEAR rROM DATE I5SUED (Complete in Triplicate) 'I Application is'hereby made,to San Joaquin County for a permit to cone',truct and/or install the work herein described. This application.is made in emwilance with San Joaquin County Ordinance Hol . 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 7'4 Job Address CityLot Site/Acreage Owner's Name r ' Address __ �' 2`� �_ar7�r�' �iasc Phone .� - i Address ��+ �� cense o. ... Contractor Q _1 LiN `t'Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well Cl UMP INSTALLATION 11 SYSTEM REPAIR ❑ onitoring Well 17 DISTANCE TO NEAREST: SEPTIC SEWER LINES .r_.-..._—'" DiSP LD. PROP. LINE FOUNDATION AGRICULTURE WELL HER WELL_ PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AR CoN TION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca ta. ell EIxcavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tr Type of Com Specifications M Public I;1 Other Delta Depth of Grout Seal Type of Grout G Irrigation �. Ap epth CI Eastern A 5ur'iace Saul Insiallnd by Repair Work Done U of Pump H.P., State Work Do Wall Destruction Well Diameter Sealing Material i Bepth Depth Filler Ma ial i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION DESTRUCTION CI INo septic system permitted if public sewer is available within 200 feet.) C Installation will serve: Residence^ Commercial — Other Number of living units: Number of bedrooms !! Character of&oil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 � � Method of Disposal Distance to nearest: Well Foundation---j— Property,Line LEACHING LINE, 0 No. & Length of lines i �' Total length/size. FILTER BED �. �1' Distance to nearest:' Well Foundation f' 4Aroperty Line _ J.._.- i _ _1 b. SEEPAGE PITS I I Depth Sire {.�. - t� f Number ` SUMPS t El Distance to nearest: Well Foundation Property Line DISPOSAL-PONOS_❑_._ I hereby certify that I have prepared this application and that the work will be done in.accordance with San Joaquin county o(dinances, state laws, and rules and regulations of the San Joaquin County �,� Home owner or licensed agent's signature cartiilea the}ollowing'. '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 compensationt laws of California." Contractor's hiring or sub-contracting signature certifies the followinq: "I certify that in the performance of the work for which this perlkt is issued, I shall employ persons subject to workman's compensa- tion laws of California." i The applican�uat�eatY�or Ire ed.ins cti {s, Cample , yawing on reverse side. igned X Title: r{ 1�,ixl - Date: J J2 V/2', 10 DEPARTMENT US�1E ONLY Application Accepted by Data 1 Area - - ul 42 `� k Pit or Grout Inspection by Date Final likn:pection by Date Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES f 445 N SAN JOAQUIN, P O BOX 2008;1 STOCKTON, CA 85201 . F FEE, AMOUNT DUE AMOUNT REMITTED CK 0 r kceivEO BY DATE P£RMIT'NO. t INFO I CASH qty �� • fH 17.24)REV.l I n 51 ml� T f Soo �� EH 14.26 ttt