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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 } PERMIT EXPIRES 1 YEARJ VRQM DATE ISSUED- (Complete in Triplicate) Application is hereby ttade,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 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Job Addrea City // Lot Size/Acreage �� �� 7 �hl71tif b h�° Phone Owner's Name ddress _ A/ R Contractor � a f! `' Address er License NO 4 Q Phone 361g-0 >� TYPE OF WELL/PUMP: WELL K WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well C1 { PUMP INSTALLAT,ION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well o DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS l� INTENDED USE- ..TYPE OF WELL PROBLEM AREA _CONSTRUCTION SPECIFICATI h5 - -� -.-•*� ,� 171 Industrial ❑ Open Bottom ❑ Man�c a r Dia, of Well Exanon Dia. of Weil Casing .Domestic/Private XGravel Pack ❑ Tracy Type of Casingca Specifications , IO public is Othpr p Delta Depth of Grout aI r Type of CJ Irrigation {, proAp ><. Depth Eastern Surface Seal Instal ` Ste' t Repair Work Done U Type of Pump e 2,B H.P"a _ State Work Done _ N Well Destruction D Well Diameter sealing Material 4 Depth rh Depth Filler Material A Depth v it TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION M DESTRUCTION G mo septic system permitted if public sewet is available within 200 feet.i Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feat: Water table depth Q SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments c PKG. TREATMENT PLT, 0 Method of Disposal S Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. 6 Length of lines Total iength/size �p FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS t I Depth Size Number SUMPS LI 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 persons subject to workman's compensa- tion laws of California." The applicant ust cap for all requir d inspections. Complete drawing on reverse siid�e. Signed Title: fir.,/ 'Y,>+��:�- - Date: PARTMENT USE ONLY AppliPnal cepted by r`�- Date _ W-3� -p1D Area P rspection b� Date �� Final Inspection by� M - -- - DateAd qrnents: C L�$'�U�. Pte-Ldc, �t.If ( k7J a3i ,, _-----•- •_ _ 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 05201 T- .INfE AMOUNT DUE AMOUNT REMITTED C SN�_ __RECEIVED BY .. DATE PERMIT NO.. . t:yu-z,tnEv.,,A}1k_Sti EM;x.26 Y