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APPLICATION FOR PERMIT �-• SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION I� P O BOX 2009, STOCKTON, CA 95201 h (209) 468-34*7 34)aAo PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made,to Sas Joaquin County for a permit to construct and/or install the trork herein described. This application is made in compliance with San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 1i Job Address . _� (p ►+1 ._ T��«-�d T� a City _� ` Lot Site/Acreage i A Lf 9 is Owner's Name ._ _.QC 1 1__beln;cz 330 Address Phone i Conlraclor eI SJn:� ,..5�Addre55 ZSD . %-3� iAI a- ;�(ak t Phane License No. i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION © SYSTEM REPAIR 0 OTHER ❑ Monitoring Well [7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FMO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .� i 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LI Indualhol ❑ Open Bottom ❑ Manteca Die, of Well Excavation pia, of Well Casing U Domestic/Private CI Gravel Pack ❑ Tracy Type of Casing Specifications M Public I'll Other ❑ Delta Depth of Grout Seal Type of Grout CI Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by ii Repair Work Done U Type of Pump H.P. State Work Done I� Well Destruction ❑ Well Diameter Sealing Material i Depth ii Depth Piller Material i Depth 11 TYPE OF SEPTIC WORK: NEW INSTALLATION 1=1 REPAIR/AODITIONIRI�_ DESTRUCTION ❑ INo septic system permitted if public sewer is + available within 200 feet.) Installation will serve: Residence Commercial-Z Other i� i. Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth O t r I SEPTIC TANK ❑ Type/Mfg opacity No. Compartments PKG, TREATMENT PLT. 0 �-� �- tr�f�,� - pp eAM�+ pLY A 4;'t;: 4ethod of Disposal I+ Distance ;o ea est: Weil Fundatiosl_ ro rty i a LEACHING LINE ❑ No. & Length of linea _ Q. =�eS Total length/size h FILTER BED (:1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number �1 SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS D 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 I rules and regulations of the San Joaquin County f Home owner or licensed agent's signature cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not Ij employ any person in such manner ss to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature it certifies the following: "I certify that in this performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa• tion taws of California." ij The applicant must call for all required inspectionq. Complete drawing on reverse side. fSigned Title: =� G Date: ^q l l FOR DEPARTMENT USE ONLY I� Application Accepted by &Z Data Area *F1`3 Pit or Grout inspection b Pe Y pate Final Inspection by Data �j Additional Comments: ,p� Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES a rr u `�rltia i ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN. P O BOX 2009, STOCKTON, CA 85201 FEE . MOUNT DvUE //ON/T REMITTED ED �(RECEIVED BY DATE P/E}RMi�ITNOQ7.t INFO CASH EH t3- IEvrinir EH-.4-1