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APPLICATION FOR PERMIT q SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCSTON, CA 95201 PERMIT EXPIRES I YEAR FROM DATE UBPF IL E COPY (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 in made in ceetpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of,San Joaquin County Public Health Services. Job Address p17 b City Lot Size/Acreage Owner's Name _/. V cess Phone Contractor Addres License No. / J ✓ S? /Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well D PUMP INSTALLATION O SYSTEM REPAIR E) OTHER ❑ Monitoring Well Li DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE ❑ Industrial f:l Domestic/ Private I'1 Public I I Initiation Repair Work Done IJ Well Destruction ❑ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Other Cl Delta Depth of Grout Seal type of Grout -..Approx. Depth I I Eastern Surface Seal Installed by Type of Pump H. P. State Work Done _ Well Diameter Sealing Material i Depth Depth ?'eller Material i Depth NEW INSTALLATION REPAIR/ADDITION I 'IDES I 1 (No septic system permitted if public sewer is / avatiabto within 200 teat,} Installation will serve: Residence _L Commercial — Other Number of living units: ,_L_ Number of borooms Character of Sart to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments „•—� PKG. TREATMENT PLT,10 t Method of Disposal Distance to nearest; Wet Foundation Property Line i LEACHING LINE C1 No. b Length of lines FILTER BED D Distance to nearest: SEEPAGE PITS I I Depth y rS� LI Distance to newest: DISPOSAL PONDS ❑ Total length/size' Well 1,01) _ Foundation Property Line `10 (2 2 - i 1 Number—,. Well Foundationf� _ property Line 8 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stale laws, and rules and regulations of the San Joaquin County HOMO 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 companas- tion tows. of Californla." ' The applicant qnyst.94111 for all r r -ed r spactions. m to drawing on reverse side. Cf Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by , o _ Date 3� �1 _13' L3' Area Z —2— Pit or Grout inspection by Date Final Inspection by _ Date Additional Comments: Applicant — RetVt n all copies to: San Joaquin County Public Health Services ' Environmental Health Permit/Services 446 H San Joaquin, P O Box 2009, Stkn, CA 95201 T IEE AMOUNT DUE INFO AMOUNT REMITTED CASH RECEIVED BY DATE >SERMI7'N0. 1 � .. fH 14-24 1ilEY. t i R 61 !j/ l _ L _ fiN 14-7e i b 11 /� /� ! /J- f'7 - � I r ,l /u f - - -- a V 3D N