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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468=3447 �UMIT 9MIRES 1_YEAR k0M D,&TE 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 V application is made in compliance ith San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Job AddrsasC h' [ � ^� City Lot Size/Acreage I Owner's NameAM,gC .,_�1�_1:1VZV Address 4��Z_'E", 1nln _ done Conlracto Address s /L �gNo Prone TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LiN£ 5 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial O Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing U Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications M Public Cl Other I ❑ Delta Depth of Grout Seal Type of Grout CJ Irrigation Approx, Depth 0 Eastern Surface Seal Installed by Repair Work Done U Type of Pump; _ H.P. State Work,Done ,..._ Well Destruction 0 Well Diameter Sealing Material i Depth Depth Filler Material L Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAMIADDITION Cl DESTRUCTION tNo septic system permitted if public sewer is available within 200 feet Installation will serve: Residence Commercial— Other 50W Number of living units: ,.J_ Number of bedrooms �-- — Character of soil to a depth of 3 feet: 1 19 IL4Z Water table depth SEPTIC TANK X Type/Mig URC42L72 Capacity&2Z2No. Compartments PKG, TREATMENT PLT. 0 � Method of Disposal i Distance to nearest: Well Foundation bf2„ property Line LEACHING LINE Cl No. & Leng6 of lines 9 Total lengthlsi:e FILTER BED ID Distance to:nearest: Well Foundation ti Property Line (� SEEPAGE PITS 11 Depth Silo ; 1v Number bee r 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 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 bicome 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 must tail for all required ins ,cti ns. Compa drawing on sa side. Signed j V OETitle: ' Date: i J. FOR DEPARTMENT USE ONLY / �� Application Accepted by } r Date._ .(��D�Co F _ Area Pit or Grout Inspection b f� y � Date� Final Inspection by � Date iqiiv Additional Comments: Inc Applicant - Return all copies to: f p SAN JOAQUIN COUNTY PUBLIC HEALTH 3ERVICSS ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEE i INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERM17'NO, • EH 13•24IIIEV.1/"5) ��420 ` 0 EHIC26 i «� f/© -3