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APPLICATION' FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 ' PERMI EXPIRES I YEAR FROM D TE (Complete in Triplicate) Application is hereby madeto San Joaquin County for a permit to construct and/or install the vork herein described. This application Is made in compliance vith San Joaquin County Ordinance Ho. 549 and 1862 and the Rules and Regulations of San f Joaquin County Public Health Services. y u` Job Address _ - City 4 Lot Size/Acreage Owner's Name D e Address SA2A Phone 7 f Contractor 6S Address T?I SGAM Akf PA License Na Phone _11LIA1? TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION VrOut of Service Well L1 Ir PUMP INSTALLATION ❑ - SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ l DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. , PROP. LINE t I FOUNDATION AGRICULTURE WELL � OTHER WELL�_ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C] Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Die. of Well Casing D Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing_ Specifications j 1'1 Public C7 Other (! Delta Depth of Grout Seat Type of Grout I I Irrigation —,Approx. Depth I I Eastern Surface Soul Installed by Repair Work Done 0 Type of Pump H.P. State Wo k D rte Well Destruction 19/ Well Diameter r_1 d Sealing Material a Depth S Depth to Filler Material i Depth TYPE Of SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION l I INo septic system permitted if public sewir-is available within 200 feet.) i Installation will serve: Residence_ Commercial— Other Number of Qft �Nurrtbei of bedrooms Character of soil toe depth of$fee . - W 0i depth SEPTIC TANK, ❑ Typo/Mfg `t Capacity No. Compartments PKG. TREATMENT PLT. I Method of Disposal ' Distance to nearest: Well;4 �; oun '} i:.Property tine p r I LEACHING LINE Cl No. b Length of Ii Total lengt FILTER BED D Distance t rasa: Well Foundation Property Line SEEPAGE PITS Depth + Siitr '-� Number- I SUMPSL1 Distance to nearest: Welh Foundation Property Line DISPOSAL PONDS 0 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 4. Home owner or licensed agent's signature oertifiee_tha following, "I certify that.in the performance of the-work-for_which.this permit is issued.1.1 shall not ._ empl'ay my parson 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, 1 shall employ persons subject to workman's�compenss- tion laws of California." The applicant Imus call for requir inspections. Complete drawing on reverse Si e. # Signed Title: 1 Date: '10-9 1 f 2 & - _ FIDEPARTMENT-USE-ONLY—yApplication Accepted by ;� �k a�t _— — Date Z Area 2— Pit or Grout inspection by Date Final Inspection by Date Addksional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San.:Joaquin, P 0 Box 2009, Stkn, CA 95201 La�t;, FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'N0. i ., +, 1 rE INFO [/ CASH -"EM i3.24 Qts 4��• f�� 1�.