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APPLICATION FOR PET ----- SAN JOAQUIN COUNTY PUBLIC HEiJ"ICES ENVIRONMENTAL HEALTH DNi420445 N SAN JOAQUIN, PHONE (2P O BOX 2009, STOCKTON,PERMIT EXPIRES 1 YEAR FROMI S (Complete in Tripli Application is hereby made to San Joaquin County for a Permit to construct and/or meta n In. application is made In compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regu Joaquin CountyPublicHealth Services. y Job Address r/ 6 '�PO� City 5*,V<"rd4✓ Lot Size/Acreage Owner's Name 61-0 /1/0r'r-1hN Address p"/sl� Phone EVr Contractor /mSO Address doer t A44!E tri �e%ul icense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C.l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_. Specifications I'I Public FI Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Sedl Installed by Repair Work Done L] Type of Pump H.P. State Work Done _ Well Destruction D Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION,I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other r7d 614 AD B Number of living units: _-/— Number of bedrooms %— Character of toil to a depth of 3 feet: C .4y Water table depth SEPTIC TANK O Type/Mfg ArW Ps I- Capacity I%Ie0 No. Compartments ?* PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE kl' No. & Length of lines $O 14 oral length/size FILTER BED ❑ Distance to nearest: Well /xs" Foundation ` Property Line ASO SEEPAGE PITS III Depth X Ir Size C Number x SUMPS LI Distance to nearest: Well ��5� Foundation l�� Property Line ��o 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 cartify 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 inspections. Complete drawing on reverse side. Signed 7L(' � Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Dateh la / Area 1 Pik rout Inspection by Date �r �' Final Inspection by / Le ""`� Date C Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 L� FEE AMOUNT DUE AMOUNT f ITTED RECEIVED BY DATE PERMIT NO. INF CASH EH 13-241REV.1/x5l 6q Y �� . . EH 114.26 F'