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� SIDE APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT iR96 ,1 YEAR PROM 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. Job Address r; 3,99City of Size/Acreage C, Ownei s Name a i Address ' �� Phone n • Cantrat: A dre )cense N4 Phon TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well Cl PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 Industrii ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Weil Casing LL2fmastic/ ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ID Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout II Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump _— H.P. State Work Done Welt Destruction O Well Diameter Se Ing Material i Depth Depth Finer Material 4 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION O REPAIR/ADDITION M DESTRUCTION G (No septic system permitted if public sewer is available within 200 feet.) d Installation will serve: Residence _; Clpmmercial Other Number of living unitE: 5 '. Number cif bedrooms Character of soil to a depth of 3 feet - War aF�t -� SEPTIC TANK ❑ Type/Mfg Capacity N n PKG. TREATMENT PLT. Cl MBsf+IM jig Distance to nearest: Well Foundation PropertyAN-a-6-M LEACHING UNE 0 No. 8 Length of lines Total lengPd:tije^ r r` ,-,� r i1 •^� FILTER BED C') Distance to nearest: Welt Foundation �FIk��pe�#Y� Erye;. LJi _:1i SEEPAGE PITS 11 Depth Si:e. Number 1" SUMPS LI 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 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 workmen'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 mu II all required in ns. Complete drawingon arse side. � Signed Title: Data:.' 7 -30 FOR DEPARTMENT USE ONLY Application Accepted by -Data �- Areal�o Pit or Grout Inspection by Date Final inspection by Data �� Z Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVI ON PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 D09, STOCKTON, CA 95201 FEE INF�O/ AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY 3�DATE pPER�M�I7'NcO. --- EH 13.24(REV.I/,i s) P1V qs7 t� 1307�1 03 EH 1.4-M