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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O 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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 4/ �i/�Q 45 SCJ(f/f'7 / `/�i' lA`.� Itl7+ ly��_ Lot Size/Acre a gob Job Address ? C'tyQi i^/ a8 Owner's Name � V J r / " r l'if!/ Address Z4 4 5'� `; r t'l V Phone 4&3 Contractor �Lr Address SX y' ` As A&� License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Ll Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PR E FOUNDATION AGRICULTURE WELL OTHER WEL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTI IFICATIONS n Industrial ❑ Open Bottom ❑ Manteca ell Excavation Dia. of Well Casing Ca Domestic/Private Cl Gravel Pack ❑ Trac Type of Casing_ Specifications ('I Public 1:1 Other elta Depth of Grout Seal Type of Grout I I Irrigation —.Ap epth I I Eastern Surface Seal Installed by Repair Work Done U pe of Pump H.P. _�� State Work Done_ Well Destr n ❑ Well Diameter sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is - / available within 200 feet.) Installation will serve: Residence Y Commercial_ Other Number of living units: j Number of bedrooms 3 Character of soil to a depth of 3 feet: rr Q'A Water table depth eT• SEPTIC TANK V Type/Mfg irc NCiQ Capacity-1.2 60 -qCQ, No. Compartments PKG. TREATMENT PLT. ❑ ��c �1 Method of Diapoapf Distance to nearest: Well _-L L— Foundation� Property Line LEACHING LINE No. & Length of lines Lj ela h Total Is gth/size 024 1) FILTER BED O Distance to nearest: Well �!_ oundation Mo a ` Is Line "70 SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 workman's compensation laws of California."Contractor's hiring or sub-contracting sig ure 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 compens - tion laws of California." The applicant must call for all reaulred inspections. Complete drawing on reverse side. Signed / Title: � A Date: 1 /(�' 9'3 ` q Application Accepted by f ,. r y,J&kGLmFOR DEPARTMENT USE ONLY A& Date s-7Ares d 2 l V t7r Pit or Grout Inspection by r 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, Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK ECEIVED BY DATE PERMI7'N0. EM 13.24(REV.1/N6) EH 11.26 [—