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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SEk.10ES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT 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. (��L J� 1 �i Job Address �t�.l.C7'L1 � �q �SL� No- A City ��I'�' Lot Size/Acreage 144 Owner's Name "��'v R U l Address r`MGtft't Phone (Zcq Contractor �L �� Address Jlob�o ��4 �Vk License No. 19 Phonee�b� TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION IC Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 43!Sy FOUNDATION AGRICULTURE WELL OTHER WELL - PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1�RaKocco jQ11 7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Ca U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing VL Specilicatlons I❑ Public )at her ❑ Delta Depth of Grout Seal Type of Grout U IrnOauon l Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction Well Diameter Sealing Material r1 Depth Depth 4A Filler Material i Depth TYPE OF SEPTIC WORK' INSTALLATION L1 REPAIR/ADDITION M DESTRUCTION G INo septic system permitted if public sewer is availabl I1 200 lost.) Installation will serve: Residence_ mmercial _ Other Number of living units: Number of be oms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: oundatlon Property Line LEACHING LINE Cl No. b Le of lines Total length/size FILTER BED n Di ce to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑ 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 Ling or ub•contrac'Ing signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ perr nss• tion laws of California." The applicant must call for all required iinnspeecttiions. Complete drawing on reverse side. Signed G��Z Title: �l� &=22 i.S� Date: l 3 Z /fY FOR DEPARTMENT USE ONLY Application Accepted by Oats Area n/ Pit or Grout Inspection by Date Final Inspection by Date 3 v Additional Comments: Applicant - Return all copies to: SAN JOAQUIN CO TY PUILIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201FEE NFO AMOUNT DUE AMOUNT REMITTED ASH ECEIVEO BY DATE PERMIT NO. EH -25 r�� » , ,r A EN .�•2a