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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES N ENVIRONMENTAL HEALTH DIVISION CCG P O BOX 2009, STOCKTON, CA 9.5201 N o (209) 468-3447 C4 — lZ tAcq S� R ?ROM PATE—MIM (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 eoeipliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquita County Public Health services, C J—Ire�- City �1� �r\Lot Size/Acreage Job Address , Address « t Phone Owner's Noma � J� ��I cru"1 W4/'D S Qjl y `I 3_�,S Phone 3 1: Contractor__�� fi'�'�_e� C _Address L� d� License No. __ --- -- of Service Well/ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F.1 DESTRUCTION ❑ Wt Monitoring Well r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 111 DISTANCE TO NEAREST: TANK SEWER LINES DISPOSAL FLD, "PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS nteca Dis, of Well Excavation Dia. of Well Casing n industrial ❑ Open Bottom ED Ma iSpecifications..- U Domestic/Private i1 Gravel Pack 0Tracy Type of Casing M Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout l M Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Wort Done U Type of Pump H.P. State Work Done_ y Sealing Material i Depth Well Destruction © Well Diameter ` Filler Material & Depth Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR1ADDITiON M DESTRUCTION Mt-INao septicable systithim emitted if public sewer is eet6) Installation will servo: Residence Commercial_ Other5 9 _ Number of living units. Number of bedrooms b Character of soil to a depth of 3 feet: l ales Tab-16 depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT,0 Method of Disposal Distance to nearest: Well Foundation Property Lina LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED n ._Distance to nearest: Well -- Foundation Property Line J� SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS I hereby comity 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 cemifies 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 taws of California." Contractor's hiring or sub-contracting signature certifies the following: 1 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." The applicant m st call for all require ins ions, mplete drawing on reverse side. Signe Tide• Data: V V' F PARTMENT USE ONLY Application Accepted by Data b Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments k Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASs INFO RECEIV D ay DATE PERMIT NO. I'1 y� 7 . EH 13•N TREY.i�ni1 —2 Err^,4•1e f