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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 ,P IT EXPIRES 1 YEAR PROM PATE 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. Job Address '� !—� S / A) ShiJ — City �� Lot Size/Acreage Owner's Name 1 r v� �Eka NAddress AC_ct KApD ksjDr,Phone Contractor i Address �� License Norte qcr-iPhone ' TYPE OF WELL/PUMP. NEW WELL WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well O PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER O Monitoring Well '' DISTANCE TO NEAREST: SEPTIC TANK ti SEWER LINES DISPOSAL FLO.AL^L PROP. LINE f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r M Industrial Open Bottom ❑ Manteca Dia. of Well Excavation *+ Dia. of Well Casing XPomestic/Private ❑ Gravel Pack O Tracy Type of Casing �C'P, r Specifications i ublic (I Other O Delta Depth of Grout Seal _� ► Type Pf Grout G Irrigation , ��. .Approx. Depth Eastern rS rface Seal Installad by-�� Repair Work Done U Type of Pump � _ H.P. r� State Work Done Well Destruction O Well Diameter Sealing Material 6 Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION 0 DESTRUCTION M (No 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 •oil to a depth of 3 feet: _ Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments _ PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. 8 Length of linos _ _ Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line _ SEEPAGE PITS 11 Depth Size Number _ SUMPS LI Distance to nearest: Well Foundation 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 laws of California." The applicant must call for atl r quire inspections. Complete drawing on reverse side, Sign d ) Title: �� —i ✓ �� F' _ Date: FOR DEPARTMENT USE ONLY Applic ionccepted by , Date J.,U` Area Pit or rout ns ctian b ► Date -ZFinal Inspection by T -- Additi.nom oPe y Z:�1„T mments: — I 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 CK 0 CASH RECEIVED BY DATE PERMIT No. y IN[O. f4A26 tiri 24Inty As,�t E`I ;� � _