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APPLICATION FOR PERU I T `./ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT EXPIRES 1 YEAR FROM DATE. ISSUED (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 with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. . l Job Address 1�, '�``t Fh �_<:.•1 if<'•' `� t City i` F(�u" Lot Size/Acreage v(�t �'l F L Owner's Name h G.:r. !► �•` Address `{ L/ ,c�..<,. �Z 1:.n r.•- t''a h �- Phonetrr r (.i K4j .0 1t+rS Contractor S,c f'=1 P<•<• �« Lha_, ;h-%Address LLt�'t�_.� f'•he t_,<,�c, Cw _License No. C " t l'•� S Phone C ( TYPE OF WELL/PUMP: NEW WELL p. WELL REPLACEMENT O DESTRUCTION O Out of Service Well Cl PUMP INSTALLATION ❑ SYSTEM REPAIR Ll OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES •�::i) ' DISPOSAL FLD.`t't *'- PROP. LINE •L FOUNDATION AGRICULTURE WELL`--%iZ OTHER WELL 'C' r PITS/SUMPS �._t`�•� - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS III Industrial O Open Bottom O Manteca Dia. of Well Excavation ig /c'r Dia. of Well Casing z U Domestic/Private �i.Gravel Pack L7 Tracy Type of Casing S•$.e.1-' `r _ Specifications Q Public Il Other O Delta Depth of Grout Seal (3� Type of Grout •t' `r �` CI Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by �'• �<+ tt�• f C.<n•• f o r�.•<t 0MIs t-� -, •`� epair ork Done U Type of Pump H.P. State Work Done Well Destruction O Well Diameter _ - Sealing Material i Depth 1-1-. ti-/ ct.• : f _, r J Depth 11;d�l a/ Au Filler Material A Depth le-, $ _< TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Ll DESTRUCTION CI INo 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 feel: ---Water table depth SEPTIC TANK U Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well __ Foundation_ Property Line LEACHING LINE 0 No. 8 Length of lines _ _ Total length/size FILTER BED CI Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well _ _ Foundation__ �— Property Line DISPOSAL PONDS O I hereby conity 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 fugulations of the San Joaquin County Home owner or licensed agent's signature candies the following: "I certify that in the pertorrnance 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 subcontracting 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 mu t call for all required t spe,ction /Complete drawing on reverse side. / / Signed t '�' i Title: -' (<,` r Date: / 1 ! `l<) i FOR DEPARTMENT USE ONLY Application Accepted by , _ _ Date Area Pit or Grout Inspection by _ Date,_� ` ` Final Inspection by Wl Dote / Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES •145 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASFI RE VED 8'r DATE ERMIT NO. • EH 13-24Ir1EV.liner 8r EN :4.20 •