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SAN JS4IAPPLICATION FOR PERMIT SAN JOAQIIIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMMTAL HEALTH DIVISION . 445 N SAN JOAQUIN PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 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 Count+y�Public Health Services. hal 7NP1,)a .Gv� City Job Address Q Lot SiSize/Acre a Owner's Name �(,fes / - Address 32Z al 7 1. Phone GU `d/�iLt�Address�Gz'7 W' tT s7VLicense hold 9 Phone Contractor - -- TYPE OF WELL/PUMP: NEW WELpe WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well Ll PUMP INSTALLATION Cri SYSTEM IJIEPAIR 0 ,OST EER 0 -. Monitoring Well �+ DISTANCE TO NEAREST: SEPTIC TANK '� SEWER LINES,; N DISPOSAL FLD. ,//� PROP. LINE �7�J 6 3) FOUNDATION AGRICULTURE WELLS A' OTHER WELL Iljj/,/ PITS/SUMPS �GIU INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack O Tracy Type of Casing�l/C- ---- Specifications 1/ , Public n Other 171 Datta Depth of Grout Seal ✓d Type of Grout I I Irrigation Approx. Depth Eastern Surface Sea$ Installed bylf!`f�F4�?—Zr;e - Repair Work Done 0 Type of Pump 1' H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material A Depth (� Depth 'Filler Material & Depth -� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 Mo septic system perrimitted it public sewer is t` available within 200 feet.) C- Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms '1 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: Well Foundation Property Line LEACHING LINE ❑ No. 3 Length of lines Total length/size FILTER BED .0 Distance to nearest: Wed foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS Ll Distance to newest: Well Foundation Property Lina DISPOSAL PONDS ❑ I hereby csnify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state lays, and rules and regulation of the San Joaquin County Homs 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 California." The applicant ,pwst f squired ip4wtlons. Complete drawing on re arse side. Signed Title: _ lL�l�`� li/pG�S/�— Date.- FOR DEPARTMENT USE ONLY l� Application Accepted by Data 3 icllq3 Area ti d Pit or Grout inspection by Date Final Inspection by � Data Additional Comments:5A.AJzU ��"� �L+ic 0►�- T q Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 A San Joaquin, P 0 Box 2009, Stkn, CA 95201FEE INFO AMOUNT DUE AMOUNT AEMITTED CASH RECEIVED BY DATE PERMIT-NO. �q CH13-24 3 24(REV.i,r 37 i