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APPLICATION*FOR PERMIT > SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 1 (209) 468--3447 PERMIT ESPIRES 1 YEAR ?R-OA-DATE L=HUEIf (Complete in Triplicate) Application is hereby trade to San Joaquin County for a permit to construct and/or install the work herein described. This application is [made in cctliance;,with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. r� Job Address --I-49O City L�U Lot Size/Acreage _ Zp C Owner's Name rase0� Phone 33 Contractor JL d Address i License No. Phone TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ 'A° PUMP,INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ., INTENDED USE TYPE}.OF WELL r-PROBLEM AREA CONSTRUCTION SPECIFICATIONS �„ * Industrial ❑ Open Bottom ❑ Manteca "Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ` `❑ Gravel.Pack" n Tracy """"" Type of Casing Specifications Q Public,ter" ' Cl Other 0 Delta Depth of Grout Seal Type of Grout CI Irrigation _ Approx. Depth 0 Eastern Su faee'Seal Installed by Repair Work Done U Type of Pump H.P. )= t State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Q Depth Filler'Material k,Depth \ _ TYPE OF SEPTIC WORK: NEWINSTALLATION REPAIR/ADOITION 0 DESTRUCTION F-I (No septic system permitted if public sewer is V available within 200 feet.) Installation will serve: Residence Commercial— Other • Number of living units: __�_ Number f bedrooms_ _ r t �- •w•� _ J Character of toil to a depth of 3 feet: # ` 3 Water table depth a(� SEPTIC TANK Type/Mfg +p71 {rg K -t Capacity No. Compartments z PKG. TREATMENT PLT.❑ r * } r Method of Disposal ' Distance tQ nearest: Well Foundation l g Property Line [ /0 } LEACHING UW ,Ll ,,,No. 8 Length `1h T Total length/size 1-5-0 t FILTER BED ' 'r ❑ Distance to nearest""` Well JiEQ _,Foundation yOr Property Line LaJ SEEPAGE PITS }' Depth __ 25 ir _Si2e (0 Number Z -__ t SUMPS Ll 4 Distance to nearest: Well f Foundation Ovf Property Line�� DISPOSAL PONDS E) 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 cenifiss 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 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 mIca r 1 req re 'nspections. Complete drawing on reverse side. i Signed Title: Date: 4'AR D PARTMENT USE ONLY Application Accepted by Date Area f r kt Grout Inspection by pate �1�--,�- -� Final Inspection by Additional Comments: �. Applicant - Return all copies to: '8" JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2008, STOCXTON, CA 05241 INFO FEE AMOUNT DUE AMOUNT REMiT'LECK D CASH RECEIVED 6Y DATE PERMIT'NO. + 9 {+7 . EN r;42e 3-2,INt:V.1in6r EH V