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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 RAS _ YEAR PROM DATE , ISSUED (Complete its 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 cci:Wliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services, Job Address _ 47zL/ WEA�M6,FI -'l ^RD — City e,A4-7- Lot Size/Acreage ?'e 4e-, Owner's Name �7AW6S 1e,46fF.E&eA77T1 Address Phone _.7 3©/ Contractor )G"4> .c_ Aloeyi`Z Address License No. r�Y��Y7G Phone - -77 TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLA MENT ❑ DESTRUCTION 0 Out of Service well 0 PUMP INSTALLATION SY M REPAIR 0 OTHER 0 Monitoring well [3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LIN - DISPOSAL FLD, PROP. LINE FOUNDATION AGRIC UAE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBL M REA CONSTRUCTION SPECIFICATIONS fl Industrial 0 Open Bottom Omit e a Dia. of Well Excavation Dia, of Well Casing U Domestic/Private ❑ Gravel Pack 0 racy Type of Casing Specifications ❑ Public I'l Other Delta Depth of Grout Seal Type of Grout M IrriOalion i _.Approx. Dept 0 Eastern Surface Seal Installed by Repair Work Done L3 Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Seals Material i Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 71 DESTRUCTION G (No septic system permitted it public sewer is J available within 200 feel.) Installation will serve: Residence Z Commercial— Other Number of living units: i Number of bedrooms 3 Character of soil to a depth of 3 feet: -- L'`- Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity. /647<.-J No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well 147 0 Foundation _ L Property Line Sd LEACHING LINE L9—No. & Length of lines r1„_� ,.,.._..__.—._ Total length/size 7_201 FILTER BED rl Distance to nearest: Well 76 r Foundation ZO Property Line S©` SEEPAGE PITS I I Depth ;Z'2 Site Numbery `(` SUMPS Ll Distance to nearest: Well �'' Foundation �3 _ Property Line ��f 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 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 California." The applicant must call for all required insp iction`s�rnplete drawing on reverse side. Signed Ar-, ,,`�(/t+�`e Title: Date: FORD PA14TMENT USE ONLY Application Accepted by 42ZZ ,� t Date _ �� Area l.R or Grout Inspection by at' e`z' /Final Inspection by r� (� I]ets. r �-�-4 Additional Comments; i Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES Qi}•, 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 85261 ` FEE INFO AMODUE AMOUNT REMITTED CAASSHH7 HECEIVED BY DATE Q PERMIT'NO. . EH '.20 1EY.i AQa EN