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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION _ P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT EXPIRES 1 YEAR PROM 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 �P-u7blic Health Servic/e�ss..] /,, /�2 i� / ` Job Address !k / 6 �j/,r SS • d City � Ot if 1L>��1'LLot Sim/Acreage Owrar's NameF-'1»1 62,ocY[ &j11, Address �� l? t 1 1.5 /fid._ tit'-[:�JTIi- Phone '� •-' � Conlracto dl- i • z i c Address/,tv),A - License No. 3� �3 Phone `rl-Or TYPE OF WELL/PUMP. NEW WELL V1 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK [t!O y -f SEWER LINES /EO ''t DISPOSAL FLO160 + PROP. LINEZ� 2 FOUNDATION 1 z t' •�AGRICULTURE WELL OTHER WELL'' PITS/SUMP INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 10 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation d Dia. of Well Casing Domestic/Private Gravel Pack ❑ Tracy Type of Casing a Specifications Public fl Other ❑ Delta Depth of Grout Seal f 00 Type of Grou13211a ❑ Irngation 2ev .Approx. Depth '91 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ '\ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material g Depth a TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION Cl DESTRUCTION CI INo septic system permitted if public "war is (� available within 200 feel.l D Installation will serve: Residence _ Commercial_ Other v Number of living units: _ Number of bedrooms1'\\F, Chancier of soil to a depth of 3 fest: 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. 6 Length of lines Total length/size I' FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 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 ust cap for all requir inspections. Complete drawing on reverse ide. �Lr Signed X r�4'IA.1.�"'=�, i-t�l 9-�_ Title: �zb Y/ rexC L CS }— Dots: F7+/ USE ONLY f Application Accepted by Date I L Z— 1 Area Pit or Grout Inspection by - /Date 4 �0 Final Inspection by �. " 1�, ' Date /� Z-� / • ` Additional Commence: - �G l� T��i G9C!✓1 u�L�f�G�'G 1%0>) s�//iJ ht,1 r C.f1lCl/bl. 01,- r W-W Applicant - Return all copies to: SAN JOAQ I COUNTY PUBLIC HEALTH SERVICE3 s�•hiO+ i� M'W ✓+?"" ENYIRONYENTAI HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 IEEE AMOUNT DUE AMOUNT REMITTED CASH RE�,IV D BY DATE DAiTE [ Z147 I'm NO. = F„,;24 1111V.1/x51 QI. �1 r� T a."vw.J /v' l� • •Z1 7 m