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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC EEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 EAR ZRQ9 DAM-MUM (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 compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations Joaquin County Public Health Services. of Ban Job Address 14+3.3 AE _5-c s e II; City�:Ze -rod Lot Size/Acreage Owner's Nama d d Phone rens 4 DO 0 �'� �� r Contractor.____ AR c r y o%1 6- Address o C arA S License No. _ I�� 2 phone 31 9S 6 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER U9 Monitoring well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Oia, of..W Afi•Excavation Oia. of Well Casing U Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications M Public III Other ❑ Delta Depth of Grout Seal _ -e �T_ Type of Grout T Fi�T ❑ Irrigation " Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done, Well Destruction ❑ Wall Diameter — Sealing Material i Depth Depth s T 7 Filler Material L Depth � TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION EJ INo septic system permitted if public sewer-is — Installation willserve: Residence_ Commercial— Other available within 200 feet.! 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 at Disposal . Distance to nearest: Well Foundation Property Line LEACHING LINE CI No. b Length of lines Total length/sire FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS LI Distance to nearest: Wall Foundation Pro DISPOSAL PONDS ❑ Property Line 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 cenifres 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 us 11 for all fired inspec ' ns, mpieto drawing on raver a side. Sign Title- Date: FOR DEPA ENT USE ONLY Application Accepted by Dat Area UT Pit or Grout Inspection byS J Date Final inspection by Det Additional Comments: 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 95201 FEE AMOUNT DlJE AMOUNT REMITTED CR IF INFO Q �f RECC91VED BY DATE PERMIT NO. . EH 13•24 fRtV. it s, 1 miv'' r )(`s 5-q--q/ 1! IV/ EH ;3•2a �J _ 7