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S� APPLICATION FOR PERkIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 REMIT 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 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 Job Address _ 1 �.� 2 (-- °.n 5 /7 l \ gtj P J l'Iry 1 7 4"' Lot Size/Acreaze Owner's Name 1 '! IJt ,r / L�� (/ li j%/� Address �l� �L it Lid i� Phone C�� Contractor �'y�� Address License No. Phone TYPE OF WELL/PUMP. NEW WELL O WELL REPLACEMENT 11 DESTRUCTION ❑ Out of Service Well O PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well C] DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/ SUM PS�� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/ Private O Gravel Pack O Tracy Type of Casing Specifications M Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout M IrnUation — 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 i Depth Depth Filler Material i Depth TYPE OF SEPTIC WOFjK: NEW INSTALLATION REPA /ADQITION Ll DESTRUCTION (No septic system permitted if public sewer is ►(� �`� (,°c':' i /1 i ' `' �- - available within 200 feet.) Installation will serve: Residence _ Commercial Other c ( ' 0 L � Number of living units: ® Number of bedrooms 1, �� J �, \v t Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, O Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE 0 No. 8 Length of lines Total length/size FILTER BED I.I 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 ❑ - J� U 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, I shall employ persons subject to workman's compensa• tion laws of C ,.,,n a." The applica t must call for required spections. Complete drawing on reverse side. / / Signed Title: —L.� [ l 0/1 Date: _1 (� OR EPARTMENT USE ONLY Application Accepted by 0 (,A.p Y� - t . _y Data 1 - ��`^ G Area Pit or Grout Inspection by }� .Ad4itional Comments: t V (} 1 Applicant - Return all copies to: EH 17.24 (REV. I/ n 5. EH ;1.26 Date Final Inspection by SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ,J 0 ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES \ 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 Date / FEE INFO AMOUNT DUECK AMOUNT REWTTED 111 CASH RECEIVED BY DATE PERMIT NO.