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i APPLICATION FOR PERMIT D�=-F I SAN JOAQUIN COUNTY C HEALTH SERVICES ENVIRONMENTAL HEALTH DIV 445 N SAN JOAQUIN, PHONE (209)468-3420 --I' P 0 BOX 2009, STOCKTON, CA 95201 t1 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. X Job Address City Lot Size/Acreage 3 ac, �( Owner's Name �T�f2 '� V -V� Address Phone z z 7 K Contractor Address_34525-AkOda 11? 112Sr09License No. 290A1,3 _ Phone TYPE OF WELL/PUMP: NEW WELL w❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION {et, SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well n DISTANCE TO NEAREST: SEPTIC TANK SEWER ONES ' DISPOSAL FLD. PROP. LINE ---FOUNDATION AGRICU1rTURE WELL ...... OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing X Domestic/Private Cl Gravel Pack 0 Tracy t Type of Casing ><l Specifications VI Public fl Other C1 Delta � Depth of Grout Seal Type of Grout I I Irrigation Y� Approxi Depth I I Eastern . ,E: Surfa a Seal Installed by Repair Work Done U Type of Pump �� H.P. / 3�______ Stats Work Done T Well Destruction ❑ Well Diame4irSealing-Material i Depth Depth —_ Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIWADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is " available within 200 feet.) Installation will servo: esidense Commercial— Other' Number of living units. Number of bedrooms Character of soil to a depth of 3 f ; W t table depth SEPTIC TANK ❑ Type/Mfg Capaci No. Compartments 7 PKG. TREATMENT PLT.❑ _ Method of Disposal Distance to nearest: Well Foundation t Property Line LEACHING LINE ❑ No. A L of linea Total le�h/,,� FILTER BED ❑ ante to nearest: Well Foundation Line SEEPAGE PI I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, at to 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 s oma subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the fa#og ify t' performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa-tion laws of CallfThe applicant u' inspections. Complete drawing on 7rrse side. Signed Title: WA 49/" Date: L � 9Z Fff DEPARTMENT USE ONLY q Application Accepted byDate ^ +Z Area (::>0, - - ntz� — Ph or Grout Inspection by Date Final Inspection by Data // g > Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE r CK INFO AMOUNT DE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. . EM 13-24(REV. 7 Eli 14411 _/ -�