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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 4 BOB 2009, STOCKTON, CA 95201 (209) 468-3447 Pte, IT EXPIRES 1 YEAR ?RQM DATE ISSUM) �{ (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'comiliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban Joaquin County Public Health Services. f �1 Job Address ! -��1,! AO --- City Lot Size/Acreage ��i�/.lC p� _..ac-g Owner's Name 5� J T�- Address �� Phone Contractor '� dress Ar�111--xff` License No. ��Phone TYPE OF WELL/PUMP: NEW WELC�X WELL REPLACEMENT Cl DESTRUCTION Out of Service Nell ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well � U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES f~ DISPOSAL FLD: PROP, LINE erx FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS fl Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing .�Domestic/Private X'G'ravel Pack ❑ Tracy Type of Casing Specifications rL/— i' M Public 'Lj I/�Ojher 0 Delta Depth of Grout Seal _Type of Grout M Irrigation s7'&[!Approx, Depth 0 Eastern Surface Soul Installed by _� Repair Work Done 0 Type of Pump H.P. State Work Done_ Well Destruction © Well Diameter Sealing Material i Depth Depth Filler Material f, Depth r TYPE OF SEPTIC WORK: NEY INSTALLATION D REPAIR/ADDITION 0 DESTRUCTION Ct INo septic system permitted if public sewer is V� available within 200 feet.) �1 Installation will serve: Residence— Commercial— Other IQ4 Number of living units. Number of bedrooms Character of &oil to a depth of 3 fest: Water table depth > SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. n Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE CI No. & Length of lines Total length/size t FILTER BED is Distance to nearest; Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS L1. Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ Y 4 I hereby certify 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 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,'l shall employ persons subject to workman's compensa- lion laws of California." The applicanj,:�5 t r3li uire mplete drawing on revery Lde. J Signed itle: YZ� ADate: FOR DEPARTMENT USE ONI. fa Application Accepted by Date ~`�—+ �~ Area /! VV Pit or Grout Inspection by Date�d �� Final inspection by_ S—. - _ DateZ /r Additional Comments: '10,j ?`1 Z(D . Applicelat - Return all copies to, SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, ,P,0 BOX 2008, STOCKTON, CA 95201FEE CK N INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. L 124IREV.,ins) q.vo t5?y,,to-0 e ©— 70 r•2a �.� --7 t—