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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 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 y /�Joaquin County Public Health Services. l� y Job Address �' �� +� A J'� /�4 /2---_ ----— City Lot SiSize/Acreage x Owner's Name oiS�4 f Address 7-7 7 -59 /2 Phone e�j 1 i t Contractor ^ 'P �� Address ' License No. Phone TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLAC ENT C7 DESTRUCTION ❑ Out of Service Well Ll PUMP INSTA ION SYST 'REPAIR ❑ OTHER ❑ Monitoring Well L DISTANCE TO NEAREST: SEPTIC T K SEWER LIN DISPOSAL FLD. PROP. LINE FOUN TION GRI URE WELL OTHER WELL PITS/SUMPS i INTENDED USE T E OF WELL PROS EA CONSTRUCTION SPECIFICATIONS El industrial Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/PrivateZGravol Pack ❑ Tracy Ty sing_ Specifications i'I Public ther ❑ Delta Depth of Grout Seal Type of Grout I I Irrivation prom. Depth I I Eastern Surface Seal Installed by Repair Work Done of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth ({ I I V Depth tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLA �TION I 1 REPAIR/ADDITION DESTRUCTION I I IND septic system permitted it public sewer is ravailable within 200 feet) Installation will serve: Residence Commercial_ Other Number of living units: _� Number of Bedrooms Character of soN to a depth f 3 feet: Water table depth SEPTIC TANK. LT Type/Mfg Capacity No,-Compartments PKG. TREATMENT PLT,Ci .1- Method of Disposal Distance to nearest; Well Foundation Property Line LEACHING LINE . No. 5 Length of lines - f�Q " Total length/size G 1A' FILTER BED O Distance to nearest: Well��Foundation - 3 o r Property Line i SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 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 Ham 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 signature certifies the following: "I certify that in the perlormance of the work for which this permit is issued, I shall employ persons subject to workman's compansa, tion laws of Callfomla." The applicant must call for required inspections. Complete drawing on reverse side. ^- `r �!1 Signed Title: „ R, AILFDate: Idx+ �T_ OR DEPARTMENT USE ONLY yi Application Accepted by Date 1 � Area 2- � Z-� _.. . _ 'Y�V Pit or Grout Inspection by ��( Date -- � Final Inspection by Date Additional Comments: ill. 4 Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, Sox 2009, Stkn, CA 95201 FEEI INFO AMOUNT DUE AMOUNT REMITTED CK N R EIYfD BY D TE PERMIT No. . Ex 13-24(REV.rirs) e Q )±7' 1 EM 14-:11111 .�+ I '