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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P. 0 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) 7. ,� j F "Job Address -79 '7_0R.N F'l [S G R� City 5��—m6ktot Size/Acreage Owner's Name tk YZ ` L\)CA al�o Address Phone d yl_ Contractor 1 Address _ t � e License No. Phone TYPE OF WELL/PUMP. NEW WELL Q WELL REPLACEMENT Cl DESTRUCTION Ll Out of S vice Well ❑ NSTALLATION C] SYSTEM REPAIR C1 OTHER itoring Well DISTANCE TO NEAREST: SEPTIC TA SEWER LINES DISPOSAL PROP. LINE FOUNDATION AGRICULTURE WELL ER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROS CON5TRUCTEON SPECIFICATIONS f_1 Industrial Cl Open Batt Manteca Dia. of Well Excavation Dia. of Well Casing I Cl Domestic/Private vel Pack ❑ Tracy Ty Casing_ Specifications i'1 Public Cl Other Cl Delta Depth of Grou Type of Grout i I Irrigatio —.Approx. Depth 11 Eastern Surface Seal Installad.by Rep ' ork Done L7 Type of Pump t' --- P- — - •i State Work Dane ell Destruction O Well Diameter [ Sealing Material & D'epth j `` 4 Depth k' Filler Material & Depth ` V TYPE OF SEPTIC WORK: NEW INSTALLATION ! I REPAIR/ADDITION i I DESTRUCTIONINo septic system permitted if public sewer is available within 200 feet.) ; Installation will serve: Residence— Commercial_ Other ' Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: t i _ Water table depth •� - SEPTIC TANK. f ❑1 tType/Mfg 1 Capacity No. Compartments` PKG. TREATMENT PLT. ❑ _ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C) No. & Length of lines Total length/size FILTER BED F) Distance to nearest: Well Foundation L _ Property Line 1 SEEPAGE PITS 11 Depth Size_ # Number ' I SUMPS Ll Distance to nearest: Well Foundation Property Line �' I DISPOSAL PONDS ❑ F i 1 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: r 6 g g: "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 must call for all required inspections. Complete drawing on reverse side. _ _ ) i ag nedX Title: Date: F r USE ONLY Application Accepted by L Date ` LZ �" 'Area' yF- Pit or Grout Inspection byr_A Dwo Fina) lnspection by � � Date Additional Comments: ^.i-t?Gf rf!�. e i t Applicant 1,,Heturn all cops : San Joaquin C unty Public Health Services Environmental Health_,Permit/_Services ., 94'5"N"8ari Joaquin, P 0 Box 2009, Stkn, CA 95201FEE ) INFO AMOUNT DUE AMOUNT REMITTED CK N ASH RECEIVED BY DATE PEAMIT'NO. . EM13-34 TREY. /M5l -�� [7U fH iM26