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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 ` 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 ceetpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address X550 .E. ACA Po p City w ' "12 Lot Size cre Owner's Name 44 A AJ C}• pAr.-r"Q Address _57e a C Phone Contractor FL-"P 4-1. 4yorl-yp Address 7 .44 APj-=4, e,4_7- Aye License No. y3`z 76 Phone -Z27/ TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well n 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 CI Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing EI Domestic/Private ❑ Gravel Pack O Tracy Type of Casing_ Specifications ( ` I'1 Public f"1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material A Depth r TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION 1 I (No septic system permitted if public sewer isj available within 200 feet.) n Installation will serve: Residence `� Commercial_ Other Number of living units: _J_ Number of bedrooms 3 Character of soM to a depth of 3 feet: _S dA11>V [SAY 44741,1 Water table depth SEPTIC TANK. O Type/Mfg eqt- 1- Capacity le,® c�; No. Companmants I— PKG. TREATMENT PLT.❑ 12 Method of Disposal Distance to nearest: Well Z 00 Foundation_ '` _ Property Line /Sn LEACHING LINE No. 8 Length of lines 2-- /rd ` Total length/size 7-0` FILTER BED ❑ Distance to nearest: Well I70 ' Foundation :Z4 Property Line i.:d ` SEEPAGE PITS I'I/Depth 24" Size 2- Number 2- SUMPS SUMPS LI Distance to nearest: Well P16 ' FoundationAm Property Line DISPOSAL PONDS O I hereby certify that 1 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 parson in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature cenifies 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 must call for aB required inspections. Complete drawing on rover"side. Signed X�.' __X Z_ Ze4�w Title: Date: Date: FOR DEPARTMENT USE ONLY 4 Application Accepted by DateArea Z Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. . EM 13-24 111Ev.1i95t �j►Jj `� .p0 � '�-{`O L4�'�'� t2 .) EH t4•7!