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P�`'t "— APPLICATION FOR PERM I T C 41,q,-e SAN 16AQUIN COUNTY PUBLIC HEALTH SJ;�RVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete is Triplicate) Application is hereby mode,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 1862 and the Rules and Regulations of San Joaquin County.Public Health Services. Job Address � Ave_ City �• Lot Size/Acreage Owner's Name tdft �• ^'B 9 re Address J*i�1 E Phone � tr Contractor_�Qe,91nA , Address 2-8 ZS' IF. A!:;4J`Re License No. 522-&8 Phone 45_-$71Z TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT O DESTRUCTION XOut of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES >SD t DISPOSAL FLD. ..� PROP. LINE FOUNDATION S AGRICULTURE WELL — OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack O Tracy Type of Casing ya PUL Specifications M Public Cl Other ❑ Delta Depth of Grout Seal _^ O Type of Grout CJ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. ' Stats Work Do Wall Destruction X Well Dism er i✓� Depth - Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION Ll DESTRUCTION G (No septic system permitted it public sewer is available 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 ',j SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments & PKG. TREATMENT PLT,0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line 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 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 laeiant IS." The apmust gall fora re ire In p . tions. Complete drawing on reverse side. Signed Title: i Date: OR DEPARTME T USE ONLY /��t'1 Application Accepted by Date 3Area '��(l `.3 y9/fl Pit or Grout Inspection by 40 Date _. Final Inspection by v , Date 3 0 '71 r / Additional Comments: a tWcn _ Applicant — Return all copies to: SAN JOAQUIN OUNTY PUBLIC HEALTN SERVICES ENVIRONMENTAL H$ALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK 9 CASH RECEIVED BY DATE PERMIT NO. . EH A-1e WL __X_ ►21Il1E�/.1/N31 EH;1. [�I 13-1 WD :D /,J bl l !y