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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONRENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I YEAR FRQM DATE (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 Sas Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Lrl City 1-/A�JDeA) Lot Size/Acreage . /a AG MA_ Address MA_ I y . Owner's Name FeA AJX Address Phone ContractorA tam Address N Vie- License No, h1� Phone S � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT-£l------->-DESTRUCTION ❑ Out of Service well ❑ " PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ElMonitoring Well C3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 17.1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications VI Public 1-1 Other Cl Delta Depth of Grout Seal Type of Grout l I Irrivation _.Approx. Depth t I Eastern Surface Seal installed by b-) Repair Work Done U Type of Pump H.P. State Work Donee Sealing Material i Depth WellDestruction ❑ Well Diameter Tiller ller Material g Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRlADDITtON I I DESTRUCTION-F-1-1NaiEseptic able w shin ZO0 lleet=led if public sower is a Installation will serve: Residence Z Commercial— Otter `-L- T Number of living units: L Number of bedrooms Character of soil to a depth of 3 feet; D�! 1- . _ Water table depth " SEPTIC TANK ❑ Type/Mfg 'P" L Cbapacity / o® No. Compartments PKG. TREATMENT PLT. ❑ J Method^of Disposal r � � Distance to nearest: Well 1 612 It Foundation P►operty tine •��- LEACHING LINE O No. & Length of lines 2- '?-1 __ Totes length/size � FILTER BED ❑ Distance to nearest: Well Fd[�� Foundation _./d'�_ Property Lina SEEPAGE PITS I Depth _ Sire Number r SUMPS LI Distance to nearest: Wall 1_1�ef Foundat'ion ZDO" Property.Lin 3� DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will,be done in accordance wi[h San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County I shall not Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compansa tion laws of California." - ° The applicant must call for all required inspections. Complete drawing onrrevers�e-side. / Signed X - Title: `ro74;1eT- Date: /?-/_?Z- - FOR DEPARTMENT USE ONLY Application Accepted by _IVA �" DatAA AreaPit or Grout Inspection by Date °•Final Inspection bDateAdditional Comments: 71 S p 12 2 r Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn,. CA 95201 FEE AMOUNT DVE AMOUNT REMITTED CASH RECEIVED 9Y DATE PERM17"N0. INFO + . EH 13-$6(REV.r/tial �A p 1 j , o� , 3 a EH%4.36r V r