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I AP`PLICATION FOR PERMIT 14 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES r ENVIRONMENTAL HEALTH DIVISION f1601 p.O BOXL2009�,VE. , PHONE STOCKTON, CA95201 RgNIT EXPIRE S 1 YEAR FRQM DATISSUED E �+/•L� i�e�0. �� (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit,to construct and/or inetall 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 Addres� - City Lot Size/Acreage Owner's Name - Address dgPo Phone Contfactor Address J �" x� License No. V 4 Phone TYPE OF WMELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out Service Well Ll SYSTEM REPAIR,� OTHER ❑ V �. Monitoring Well PUMP:.INSTA .� ` LLATION ❑ DISTANCE TO NEAREST: SEPTIC TANK '� SEWER LINES_ DISPOSAL FLO. PROP. LINE FOUNDATION _ V AGRICULTURE WELL _Y OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSt Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia: i f Well Casing Domestic/Private f-❑ Gravel,Pack. E7 Tracy Type of Casing Specifications 1'l Public 1I.1 Other 4 - f 1 Delta Depth of Grout Seale Type of rout { I I Irrigation i Approx,-Depth� J.;1�,Ea�stern Surfface Seal Installed by Repair Work Done 7 Type of Pump �ij •• -il H•P• b� j- State Work Done I PQ Well Destruction El Weil Diameter `� L Sealing Material & Depth Depth r Piller Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION t-IwtiREPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted it public sewer is available within 200 feel.I Installation will serve: Residence Commercial� Other Number of living units: Number df bedrooms Character of soil to a depth.o(3�feet: - --• F Water table depth 1 , SEPTIC TANK ❑ Type//fg C apaciiy No. Compartments 1 'y PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line r R. LEACHING LINE Cl No. &Length of lines Total length/size ([� FILTER BED Cl Distance to nearest: Well Foundation Property Line l 1 j r SEEPAGE PITS 11 Depth Size { Number DO DISPOSAL 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 r 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 T,, employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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." 011 The:pplic t calf for all required ins tions, mplete drawing on rev a side. Signd Title: Date: FOR DEPARTMENT USE ONLY �} Application Accepted by Date � —�� u Area � - -.-1 Pit or Grout Inspection by Date Final Inspection by Date ` 1 Additional Comments: Applicant,– Return all copies to: San Joaquin County Public Health . Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CKGASH RECEIVED BY DATE PERMIT NO. N_ t Eli 13.24IREV.i{R5I INFO 4s7oo �� 7-- s--* 10-17M, EH 14-2e