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. YAPPLICATION FOR PERld I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 41 ENVIRONNMTAL HEALTH DIVISION AYMEr 445 N SAN .TOAQUIN, PHONE (209)468-34Wt-CEIVED P O BOX 2009, STOCKTON, CA 95201 CT 15 w PERMIT EXPIRES 1 Y ROM DATE ISSU JOAQUM C('"""� (Complete in Triplicate) puSt_lr�lG��yZIApLH A M «�SO�l ` Application. is hereby made to San Joaquin County for a permit to construct and/or i �Q�Y11sib�li�erein described. This fypplication is made in compliance with San Joaquin County Ordinance No. 549 and 1962 and the Rules.,and Regulations of San � aquin County Public Health Services. /q�J�( 24-; a/d-.3 `L 1 /D r City Lot Size/Acreage Job Address Q 000 VBG G�- Address �Q Y Phone Z Owner's Name -7 j �r j Contractor �� Se�t>r Address 3/'21 w'1 Q License No. WIN-7f Phone` rJ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR 11OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL &a OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing 1 �Industrisl ❑ Open Bottom I 'IVlanteca Dia. of Well Exca��vlIation -lr g El Domestic/Private Grave! Pack ❑ Tracy Type of CasingLI Specifications I'I Public El Other fl Delta Depth of Grout Seal l Type of Grout I I Irrigation Approx. Depth I 1 Eastern Surface Seat Installed by Work Done U Type of Pump r H.P. w State Werk Done- Repair _ 15,y Sealing Material 4 Depth ka 'r Well Destruction (3 Well Diameter )� , Depth Filler Material A Depth zxg TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is ave ilabie within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line Q I Total len th/size LEACHING LINE Cl No. 6 Length of lines 9 FILTER BED 0 Distance to nearest: Well Foundation Property Line I SEEPAGE PETS 11 Depth Size Number (� SUMPS L1 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 conities 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 componss- tion laws of California." The applicant call f all requir ins Complete drawing on reverse side. Signed Title: �« dliie e. Date: OR DEPARTMENT USE ONLY 19� Date A9 z� Application Accepted byA�� 7r Pit or Grout Inspection by ate Final Inspsetian by Date Gam` ti r Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Jrr� Environmental Health Permit/Services Stk �� - p 445 N Baa Joaquin, 1? O Box 2008, Sticn, CA 95201 /VAY/ k I FEEAMOUNT DUE (gMAMOUNT REMITTED C;AK$H I RECEIVED BY DATE PERMITNO. I/ . EH 13- INFO 24 IREV. i ti s� 7 694 i�c'' J� I EH 1628 6