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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION _ J P O BOX 2009, STOCKTON, CA 95201 y (209) 468-3447 1990 PERMIT EXPIRES I YEAR PROMc teAT ISSUED L;�VI, "MENTAL(Complete Application is hereby made to San Joaquin County for a permit to construct and/or install tha�}herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and,Lkk and Regulations of San Joaquin County Public Health Services. - AA( \ Job Address ��`f ly�✓L� ✓� City S�7C'khl)t-' Lot Size/Acreage TAddress /V3' ZOwner's Name S one r ConlraC to( 5F1rT I�YI �?r ��IC Address . � �'b d �rS Lcense No. 5127 Pho�e ' 9.� U�� °-712 TYPE OF WELL/PUMP: NEW WELL ❑ 'NELL REPLACEMENT (_l DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Monitoring Well lbe >50 > Sc ' - Sr: Sz7 Br°�'r� rr DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE S0 FOUNDATION !O AGRICULTURE WELL OTHER WELL CICO f PITS/SUMPS /00 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 0 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1 M Public A Other bO rrT. ❑ Delta Depth of Grout Seal Type of Grout G Irrigation L Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material L Depth 1 �' Depth Filler Material L Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION M DESTRUCTION CI (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Typa/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal C Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 1-1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I 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, 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 subcontracting 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 must call for all required inspections. Complete drawing on reverse /side. Signed X �W Km,A,kr Z� Title: l�?fl�t cr;l��f��0-1 y- /Z Cl�` / r J _ Date: / FO= SE ONLY Application Accepted by DateAOL Pit or Grout Inspection by Date Final Inspection by Date,_:' r Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMIT N0. �} 7, c) 0-1,33-5 r EH I3-24 111EV.r i n Sr �{ 7' O ,j ?