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APPLICATION FOR PERMIT O SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PRRNTT 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 1s made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. t 3rtU rr2Alt bl�'r�. _ Job Address '?rk �'^Y 12ct 7'E' ��^��5 r��^nY City /22 x Lot Size/Acreage 6 Z Owner's Name Address ;800' 3)QVNCh1-r Phone yes ?S 2� Contractor Address I I ii-O ,9 54-• S!ftWhicense No. `^tz2?o`P Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitori W 11 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rr n Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing 21 U Domestic/Private -ErGravel Pack Tracy Type of Casing Specification (.1, `{O _nc,2D M Public f-1 Other O Delta Depth of Grout Seal S Type of Grout G Irrigation _Approx, Depth ❑ Eastern Surface Seal Installed by Repair Work Done U Type of Pump �� H.P. State Work Done _ Well Destruction ❑ Well Diameter 2 Sealing Material i Depth R-0 .!Vf_ Depth ZFiller Material i Depth Msn�crc� SZ+� S-Z6 TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADOITION ❑ DESTRUCTION CI (No septic system permitted it 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 Cl Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ J-1 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 VA 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 must call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: DEP ENT USE ONLY AY Application Accepted by �j Data Z Ara Pit or Grout Inspection by _ Dat �// Final Inspection b Date 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 INFOEjAMOUNT DUE AMOUNT REMITTED CK If I CASH RECEIVED BY DATE G PERMIT NO.. . EN 13-24 +i�li U � .10 �� :4. EH:�.2a ll