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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �— ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 3 - (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 Sade in cospliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. _ (� ALO g Job Addrsw Z.�h�C_e`-�ra � �y ��-I � City �-`T� k Lot Size/Acreage -sT Owner's Name ��-t G ��^t�11ME ress J��E Phoma -'�J`i—0 Contractor kIN, �t� t�kl�L� L Addr s G1boI�L.M.ALl�s2�W PI�icense No. 7 W> Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION Ll Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER O Monitoring Well LT DISTANCE TO NEAREST: SEPTIC TANK t SEWER LINES DISPOSAL FLD.� PROP. LINE '`� FOUNDATION � AGRICULTURE WELL OTHER WELL PITS/SUMPS LIUD r, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT ON /D n Industrial X Open Bottom O Manteca Die. of Well Excavaattioonn._. Dia:of Well Casing XDomestic/Private C1 Gravel Pack O Tracy Type of Cssing a t G!I Specifications l M Public fl Other O Delta Depth of Grout Seal t�ALType of Grout 1 'Qlfdgation _Approx. Depth ❑ Eastern Surface Seal Installed by V A C_ Repair Work Done U Type of PumpSHl3NhEl, A-&.P. .,50 Z 3 State Work Done Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 1 REPAIR/ADDITION 0 DESTRUCTION G (No septic system permitted if public sewer is S available within 200 feri G' Installation will wivm e: Residence_ Commercial_ Other Number o1 living unite: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. CIMethod of Disposal Distance to nearest: Well Foundation Property Line (b LEACHING LINE ❑ No. 6 Length of lines Total length/size FILTER BED Ll 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 comity-that 1 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 cemifies the following. "I certify that in the performance of the work for which this permit is issued, I shell not employ any person in such manner as to become subject to workmen's compensation laws of California." Contractors hiring of sub-contracting signature certifies the following: "I comity that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- rich laws of California." The applicant as call l all required inspections. Complete drawing on reverse side. p, Signed n Title: C-on l t� ACX 0 Data: _ tl - 1 90 DEPARTMENT USE ONIy 1 p p, I' Application Accepted by �'11 ,YM^ Date -_ \- l— 1 Areae Pit or s�r cat Inspection by I" Date Final Inspection byA '�D��l Date T— Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES r_ 445 N SAN JOAQUIN, P 0 BOK 2009, STOCKTON, CA 05201 'l`1L'�` FEE AMOUNT DUE A OUNT REMITTED CK RECEIVED BY DATE PERMm' INFO CASH �5a 13.7„1 I IIEV.Ilmu tv't! La 9�i2- L a 3