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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-a4-1-7 / PE<�TT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Appli-tLion 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. 5L9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address y.s /ti- 1Gf/�9 ki�1 City' Lot Size/Acreage c ' Na Address " 70CJ Owner on ractor slZOZ License No.7-923 1-6 Phone .?-3013 TYPE OF WELL/PUMP: NEW W LL WELt REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well O PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well X DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE /� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS InindustrialAgppl,�, d O Open Bottom ❑ Manteca Dia. of Well Excavation 0 / ,,// Dia. of Well Casing i� U Domestic/Private ❑ Gravel Pack Tracy Type of Casing --(C4N 4 cd P✓Cr/Specifications ❑ Public *)< Other O Delta Depth of Grout Seal ti 6o .4 Type of Grout'r�94-f r -1 IrnUetion IQfApprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter !j� /fir, Sealing Material i Deptr S%B AD—W1% O- Depth / Filler Material L Depth �4 TYPE OF SEPTIC WORK: NEW INSTALLATION 1 REPAIR/ADDITION E'1 DESTRUCTION G (No septic system permitted if public sewer is available within 200 feet.! Installation will serve: Residence _ Commercial _ Other {rte} Number of living units: Number of bedrooms V j Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg ' Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. 8 Length of lines Total lengthisize FILTER BED D Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 4ancf5� I hereby certify that I have prepared this applicat on and that the work will be done in accordance with San Joaquin county ord nances, state lawsr- rules and regulations of the San Joaquin County (f^, 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 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 ermit is issued, I shall employ persons subject to workman's compensa• tion laws of California." The applicant mut call f r all re rred inspections. Complete drawing on reverse s de. Sign Title: Date: 6/ T FOi3i,DEPAR USE ONLY Application Accepted by Daro Area -7 Pit or Grout Inspection by Date / ( Final Inspection by { Date j Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 iFEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. EH 1)N 1AEv. ry,