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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 it PERMIT FIRES 1 YEAR FROM DATE Y0M (Complete in Triplicate) Application Is hereby made to Bap Joequia County for a permit to construct and/or install the work herein described. This application is sade in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address [ / S h Is City Lot Size/Acreage n p // �L Owner's Name _ z7 V Address /%2 /- ESfe? Obt -ge'/101Cr Phone N n Contractor N04' ALI sn, ^ Address 7 S � 1_reoh Ok / License No. Phone TYPE OF WELL/PUMP: NEW WELL /� WELL REPLACEMENT ❑ DESTRUCTION Ll Cut of Service Well ❑ PUMP INSTALLATION ® SYSTEMtREPA1R ❑ OTHER O Monitoring Well 13 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS it ❑ Industrial 0Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing Domestic/Private Ell Gravel Pack Type of.Cosing II Specifications [7 Public I�1 Other C1 Delta of Grout lOa wrf' Type of Grout- 0 ❑ Inigation pprox. Depth ❑ Eastern Surface Ss Installatl 11 Repair Work Done ❑ ypor of Pump � H.P. tate Work Done- p Well Destruction Well Diameter 6" 'Sealing Material 6 N - split 2S!2 Piller liaterlal i In TYPE OF SEPTIC RK: NEW 1NSTA LLATION 0 REPAIR/AODITIO ESTRUCTION 7 (No septic system permitted it public sewer is available within 700 feet.) Installation will serve: R Other Number of living units: _ Number of bedrooms Character of wil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/M1g Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line t LEACHING LINE ❑ No. B, Length of lines Total length/size FILTER BED CI Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size ° Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby meNty 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 certifies the following: "I certify that In the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of Celilornis." Contractor's hiring or subcontracting signature certifies the following. "I certify that in the performance of the work for which this permit is issued.(shall employ persons subject to workman's compensa- tion laws of California." : The applicant must call for all required Inspections. Complete drawing on refer Jw side. c q Signed -.-.. L✓U""'p"'"`�`r�'+ Title. S?/-5 - .Y`Y V/ C_jr' Data: FOR DEPA SE.OiJLY J . Application Acceptby Date D Area Pit or Grout Inspection by Date Final Inspection In Dety Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 'll ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOK 2009, STOCKTON, CA 85201 FEE OUNT DUE AMOUNT REMITTED CK RECENEO By DATE PERMIT NO, INFO �� CASH Q ^ c . ER tE.ia 0o 74 INV.tin er 5"�v / Y f - K ,J EM t