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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I . ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOC%TON, CA 95201 PERMIT MWIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application In hereby made to Ban Joaquin County for a permit to construct and/or Install the vork herein described. This application is made in cottilliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban Joaquin County Public Health Services. a _ n�� Job Address � �3�3t /"r 1`co'W 2<> �,�-yy, City ��/"Y Lot Size/Acreage Owner's Nam/e !_,p./[P��t G/I�QGC- _ �„q�l /Adddrr�ess/� I�S Phone Contractor l 9 I Z_ I Address License N Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well 0 PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION f AGRICULTURE WELL - OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing_. Specifications I'1 Public I:1 Other '-� F1 Delta Depth of Grout Seat Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seat Installed by 1'f1 Repair Work Done 0 Type of Pump 1 H.P. State Work Done_ v Well Destruction 0 Well Diameter }- 9e�alirtg Material i Depth I� Depth Filler Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I ..DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Other ?3�2-t;� Number of living units: _ Number of bedrooms r — Character of stillto•depth of 3 fest: ' ` Water table depth 16-0 SEPTIC TANK. 19' Type/M1p 707144�t — QyL' - Capacity No. Compartments PKG. TREATMENT PLT. 0 1.. r Method of Disposal Distance to nearest: Well Foundsn_L�, Property Line —/ . •.i f1. .. LEACHING LINE LY No. 8 Lengtli'df-lines vwl- Total length/size / w FILTER BED FY Distance to Xnwrest: Well Foundation -24A—Of—- Property Line n SEEPAGE PITS , � k.F�Depth -2,'!i_ ' = Sire ,,�N�umber SUMPS LI D � 'Distance to nearest: Well �7 0/ , Foundation e / Property Lina 2 DISPOSAL PONDS 0-1 .�,. il 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: PI 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 workmen's compensation laws of California." Contractor's hiring or sub-contracting signature unifies the following; "1 certify that in the performance of the work for which th4 permit is issued, I shall employ persona subject to workman's compensa- tion laws of Californle." -•.I _ The applica call or td1Y uir mapectiona.Complete drawing on reverse side. - Signed 1L Title: Date: y/ FOR DEPARTMENT USE ONLY +� Application Accepted by s//r Pate '11.3 Area Ph or Grout Inspection by �fr,,. '� ,y�Qate ,a �, Fin I Inspeeibn y _-� Dae i Additional Comments:" ' /ter'•' Sp�� r. , Applicant - Return all coD3ea to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin,-P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMtrrE ECEIVE By DTE PERMIT NO. If EDF,EE w^ . EH;124(REV.l/x5) fH 1676