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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 j... P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE S (Complete in Triplicate) Application is hereby made.to Sas Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address City j 'a, Ce0MI+ Lot Size/Acreage Owner's Name Addresses � Phone Contraelor AVSpy Address Od,Z 9,1-VC u1" Ale- License NohW` ", Phone TYPE OF WELL/PUMP: NEW WELL ❑ WECL REPLACEMENT n , DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION 0.1 SYSTEM REPAIR ❑ �� OTHER ❑ Monitoring Well Q 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 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ' Dia. of Well Casing Cl Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ {� Specifications V\ 1'1 Public Cl Other n pelta Depth of Grout Seal•�-,�, Type of Grout f I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. ' . State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth`,I TYPE OF SEPTIC WORK: NEW INSTALLATIO 1 REPAIRIADDITION I 1 DESTRUCTION'1'1 1No septic system permitted if public sewer is f available within 200 feet.) � � x Installation wilt some: Residence Commercial— Other M ok*i 1T1 H ep-r IC. ' Number of living units: Number of bedrooms 3 s` Character of soft to a depth of 3 feet: SA Aod Water table depth r� a SEPTIC TANK. . 16 Type/Mfg A-y_ GHS_TCapacity cJt7 Nod Compartments 7- PKG. TREATMENT PLT.❑ Method of Disposal + F Distance to nearest: Well, t C1a Foundation .� r "� Property Line LEACHING LINE $T No. 6 Length of lines "" p r f Total length/size t ,7 G FILTER BED ❑ Distance to nearest: We'll GG Fou dation +c -Property Line SEEPAdE PITS 11 Depth --_ «"� � Size Number—— 3r-t SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Moms owner or licensed agent's signsttfre 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 fosowing: "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 appllieant must call for all required Inspections. Complete drawing on reverse side. Signed) Title: pate: FO EPAR Application Accepted by Datee Ar.at�i R Pit or Grout Inspection by Date Final Ins ction b Additional Comments: G Applicant :- Return a 1 copies' to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Boa 2009, Stkn, CA 95201 FEE w INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'N0. _ P ,WAS/ !! + EN 14-2 (REV.r/e 51 //7777 ( / �� ""� / �� Of EH t1.2a / t�}