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APPLICATION FOP6 PEP-MIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PFJIXIT EXPIRES 1 YEAR PROM 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. n Job Address (J r7 �04/t6S /Z.O City Lot Size/Acreage a � Owner's Name �� e It wrf'y Address �c✓`z - Phone Contractor 4 - Fv 1( c,4 Address 9—R��I` t'T License No., Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION C 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 ❑ Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private O Gravel Pack O Tracy Type of Casing_ Specifications M Public 1-1 Other O Delta Depth of Grout Seal Type of Grout 0 Irnuation Approx, Depth ❑ Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth U TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 0 DESTRUCTION G JNo septic system permitted if public sewer is _ available within 200 feet.) Installation will serve: Residence Commercial _ Other Number of living units: i Number ofPPbedrooms C Character of soil to a dof 3 feet: CA-1 V Water table depth ept SEPTIC TANK Type/Mfg e4-L, (-0rl re Capacity I 4 6 No. Compartments PKG. TREATMENT PLT. C1 , r Method of Disposal Distance to nearest: Well 100 Foundation _czL- _ Property Lines J_ LEACHING LINE No. 8 Length of lines _ 46 Total length/size �e FILTER BED Cl Distance to nearest: Well i ;=' Foundation � Property Line SEEPAGE PITS LIDepth 1):S1_ Sixe -73 3 Number r r SUMPS LI Distance to nearest: Well � _ Foundation _:7,< Property Line _ DISPOSAL PONDS O 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 la vs of California." The applicant must call for a required inspections. Complete drawing on reverse side. a Signed X I A f; ;,� , Title: ✓ �'� Date: FOR DEPARTMENT USE ONLY Application Accepted by Dace Area � Date Grout Inspection byFinal Inspection by , 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 FEE AMOUNT DUE AMOUNT REMITTED I CK 0 CASH RECEIVED BY DATE PERMIT NO. INFO EH 1324 1ItEV.iin5i EH A-26