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APPLICATION FOR PERI!I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION - 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOB 2009, STOCKTON, CA 95201 , PERMIT EXPIRr,S 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 appllcation is made in cotiplience with San Joaquin County Ordinance Ho. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 3,50 �• CsedyrYQY +' ooin - __ ___-_ City frd K]np/100' Wt Size/Acreage J?. Owner's Nama GYA i41'r S Int T h Address S'0 of 1`fes G7- Phone Contractor 4 46L74' g So Address Gere V4* License No. ��T w Phone TYPE.G"- ELL/PUMi?,: m NEW WELL �L WELL TIlEPLACEMENT,1.1 -DEST.RUCTION.❑ Out of Service Well ❑ PUMP INSTALLATION OSYSTEM REPAIR O OTHER ❑ y Atonitor}rig Wel] ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES OISPOSALIFLO. PROP.. LINE � FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS, r INTENDED,6SE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 4 C7 industrial, ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing (_l DomastiW Private !. O Gravel Pack O;Tracy Type of Casing_ Specifications F) Public Cl Other Cl Delta Depth of Grout Seal Type of Grout I I Irrivalion �.Approx. Depth 11.1asiern Surface Seal Installed by Repair Work Done LJ Type of Pump H.P. State Work Done Well Destruction O Well Diameter Seiuling Material ti Depth Depth Filler Material i Depth 1 n TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDtTIONJX DESTRUCTION I I INo septic system permitted if public sewer is w 1 available within 200 feet.) Installation will serve: Residence_L_ Commercial— Other C'""'" "t Number of living units:._ Number of bedrooms Character of soN to a[depth of 3 feet: Water tle depth - SEPTIC TANK. O Type/Mfg r r a capacity-= No. Compartments PKG. TREATMENT PLT.❑ , r Method of Disposal Distance to nearest: Well- ''"'° -Foundation--' Property Line LEACHING LINE iI No. & Length of lines F •�' `��,� '�:_. '7ataP"te'ngth/sire FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS X Depth -9J% Size 36 Number x- SUMPS LI Distance to nearest: Well -1199 Foundation P operty Line DISPOSAL PONDS ❑ E 1 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 Son Joaquin County + .4 l y I 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 t6 become subject to workman's compensation laws of Cal'i#ornis," Contractor's"Airing.or sub-contracting signature certifies the following: "I Certify that in the performance of the work for which this permit is iesuiid,'I shall employ parsons subjectto Yaorkman'a compensa— tion taws of California." crt The applicant M COP for all required inspections. Complete drawing on reverse side, t Signed _ -- Title: Date:' , FOR DEPARTMENT USE ONLY `t ttr '�i' (!ddit I allon Accepted byAJA Date resrout IrnpeCtion by Date � 1 Final Inspection by Date ional Comments: Applicant - Return all copies to: San Joageldo County Public Health Services ` Environmental Hearth Permit/Services 445 N San Joaquin,-2_0 Box 2009, Stkn, CA 95201 E EE INFO AMOUNT DUE ,AMOUNT REMITTED �!< H ECEIVED SY ATE' PERMIT'NO. EH t (�/