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• APPLICATION FOR PERMIT • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-544734.aO PERMIT EXPIRES i YEAR NROM DATE ISSUED (Complete in Triplicate) Application Is hereby made,to San Joaquin County for a permit to construct and/or Install the vork herein described. This application is made in cozipllance vlth San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin Country Public Health Services. C -{,.�� Job Address / L I `� ' ` ) 1'n ✓� _ Cit"y s-ty r- r"•r Lot Size/Acreage Owner's Nam/e� Kq (r��I �� Mar^-F-in Address 1032 ..1 t- h1 h(//'S f___ Phone �— Qp�3� Contractor wafer WOr� Address CL n 51+ EfC° License No. Phone �� O -3� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 1 I0+0 ❑ Industria ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Diak of Well Casing U Domestic/Private ` - ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I❑ Public 1:1 Other ❑ Delta Depth of Grout Seal Type of Grout C3 Irrigation _Approx. Depth O Eastern .Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done O 1 r 3 Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION LT DESTRUCTION CI (No septic system permitted it public sewer 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 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll 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-'r' call for all required inspections. Complete drawing on reverse side. Clk Signed X__JOtTtsJ.- C\ Title: Date: 11-A- FOR DEPARTMENT USE ONLY Q Appf scion cep ced by IE11.�'�� Date 3 --F-� Area �• r.•pyt�napaction-by � � Date '/ / Fina(Inaoection by(J_' /^"� Date 3�ir �l Additional Comments: - Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 INFOFEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT N0. IFEE ,�-t �]�� /CSASSH EN 12-2x 111EV.11.51 `fj �'- r �� EN:620 lJ !/ .J