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APPLICATION FOR PERMIT SAN J7'UAQUIN COUNTY PUBLIC HEALTH MVICES ENVIRONMHEALTH DIVISION P 0 BOX 2009. STOMTON, CA 95201 (209) 468-3447 PERMIT EXPIRES 1. YEAR ?ROM DATE ISSUED (Complete in Triplicate) Application is hereby made.to San Joaquin County for a permit to construct and/or install the wok herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rulelkuad Regulations of San Joaquin County Public Health Services. Job Address --75-5-3 City ! /7 Lot Size/Acreage �; kfyy " Owner's Name �� r Address �5 3 /i Phone Contractor Address S �- / License No. Phone ;73- '7,1`1 TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 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 it Industrial U Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack O Tracy Type of Casing Specification M Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout G Irngation — Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material Depth Depth Filler Material i Depth G TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION DESTRUCTION G (No septic system permitted it public sewer is J available within�00 feet.) Installation will serve: Residence _ Commercial ,C_ Other —T 8 1e // lQ�� "vv/ Number of living units: Number of bedrooms Cna,yy��fyf lf� kli. Character of soil to a depth of 3 feet: %i Water table depth SEPTIC TANK ❑ 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 length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number 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 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 inspectio s. Complete drawing onreverse side. / C` Signed Title:�1�xt�2 Z- Date: FOR DEPARTMENT USE ONLY 7 / Application Accepted by /%%?� � e�1� Date 1.;2 'h Area (v Pit or Grout Inspection by Date Final Inspection by Daw 4 Additional Comments: 'Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES y ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO, EH 4114 IAEV 1 .5 EH '/.2a