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s APPLICATION FOR PERMIT SAN JOAQUIN COUNTY .PUBLIC HEALTH SERVICES t ENVIRONMENTAL HEALTH DIVISION ► P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 YEAR R (Complete in Triplicate) I Application is hereby made to San Joaquin Count for q y a permit to construct and/or install the work herein described. This application is made in coarpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address ___./Q704 LAI, NAL y1Z-1j� City__S7/L/ Lot Size/Acreage 17J�X 3��3 Owner's Name E Address'3.12,( 'lLi�21R,A�c -MA/ Phone k Contractor &al j2_> Address7Al. Abi,�ffLB i License No. `��Y7G _ Phone -r 9 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl - DESTRUCTION ❑ Out. of Service Well rl PUMP INSTALLATION 0 SYSTEM REPAIR O OTHER ❑ Monitoring well iI E DISTANCE TO NEAREST: SEPTIC TANK •SEWER LINES DISPOSAL FLD, PROP. LINE' FOUNDATION IAGRICULTURE WELL OTHER WELL ^'' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 industrial ❑ Open.Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing �_. . U Domestic/Private' 4. ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public i-1 Other ❑ Delta Depth of Grout Seal Type of Grout Cl trngalion �. Approx. Depth ❑ Eastern "+, Surface Said Installed by Repair Work Done 0 Type of Pum O . ''+' Pump ;,•H•P• i _ State Work pone � ah Well Destruction ❑ Weil Diameter /Sealing Material &',.Depth i Depth Filler Material-.i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION LI DESTRUCTION CI (No septic system permitted if public sewer is available within 200 feet.) G Installation will serve: Residence ✓ •_r Commercial Other �� 77 Number of living unity __L Number of bedrooms—ba— Character _ ,� Character of soil to a depth of 3 feet: Water table depth �! SEPTIC TANK; ` Type/Mfg I' Pqi-L, Capacit Jx+a No. Compartments L EKG. TREATMENT PLT, ❑ 4 r Method of Disposal Distance to nearest: Well Foundation Z9L_ ` , Property Line",_ O_` LEACHING LINE No. & Length of lines _�' FT5'� _ Tonal length/size,D.r FILTER BED C1 Distance to nearest: Well J. Foundation �.�� Property Line � SEEPAGE PITS lie Depth �-S r Size. 3"� " ` Number SUMPS ; LI Distance to nearest: Well, —Foundation._/..Ed[:!?r� .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 Sen Joaquin County _ Home owner or licensed agent's signature certified the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any poison 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 sonify that in the performance of the work for which this permit is issued, I chili employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections,_ omplete drawing on reverse side. Signed Title: Date: ,/ 9 -T9,,._� F DEPARTMENT USE ONLY Application Accepted by or. Date Area Pit or Grout inspection by "Date Final Inspection by Date dt' Additional Comments: a Applicant - Return all copies to, SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' --- --lok- n-•--=ENVIRONMENTAL-�HEALTH DIVISION PERU I T/SERVICES, 445 N SAN JOAQUIN, p_O BOX 2009, STOCKTON, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED GK RECEIVED BY DATE PERMiT'NO, INFO GASH EH • EN *26 EY.I In y+ t C � q q I cccccc�� u c v� ��3(0