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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 YEAR (Complete in Triplicate) Application is hereby made,to Sam Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San J in County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. + Job AddressP�2 [ ity Lot Size/Acreage J I Owner's Name . +` Address ai Phone Conlraclor 055 '`�rn`f - Address CP--).JlLl. �-�'�G01"� 1'9flicense No.� Q(o-72 Phone T�`'�� 4 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION of Service well ❑ PUMP INSTALLATION C} SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well [7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS [g CI Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy :Type of Casing Specifications rl, M Public Cl Other ❑ Delta (Depth of Grout Seal Type of Grout Cl Irrigation Approx. Depth 0 Eastern Surface Seal Installed by Repair Work Done U/Type of Pump H.P. State Work one�. Well Destruction t2 Well Diameter __._! a— �fn8 rial i Depth P O II � Depth �-5yFiller Material i Depth + TYPE OF SEPTIC WORK; NEW INSTALLATION 0 REPAIR/ADDITION LT DESTRUCTION Cl (No septic system permitted if public sower is I available within 200 feet.) Installation will serve: Residence Commercial_,_•,,, -Other Number of living units: Number of bedrooms J Character of soil to a depth of 3 feet: .Water table depth - �SEPTIC TANK ❑ Type/Mfg Capacity I No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line 3 LEACHING LINE ❑ No. & Length of lines I ` Total length/size F FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number ,y SUMPS LI Distance to nearest: Well F6undation Property Line k. 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. ' Contractors 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- tlon laws of California." The applican UuA call for all re ed inspsctians. Complete drawing on reverse side: SignedTitle: _ _ . 51 � Date: '� �� FOR DEPARTMENT USE ONLY Application Accepted by Y Date -r Area 2` Pit or Grout Inspection by Date Final Inspection by Date Additlonal Comments: Applicant - Return all Copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 85201 FEE E&0,06) AMOUNT DUE A/MOUNTflE`1MITTED CK _ RECEIVED Sy DATE PERMIT NO. + EM 13.24'IREV.1/H5r Xv,EH;128rt/ p(� • /ter �_.__