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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE S (Complete in Triplicate) Application is hereby made to Ban Joaquin County for a permit to construct and/or inetall the work herein described. This application is made in conpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. �2 City MAC-AG. Lot Size/Acreage Job Address - Owner's Name f�/� I3 �V'� '� Address -3/000 PRl1&4 R lA E A✓� _ Phone< , 4-NC-7 5.4A'777 Gz-4.-,4 Contractor rtAq yfALclnu� _ Address ,L0R License No. Phone '397/ TYPE OF WELL/PUMP: _ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION G SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L3 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 Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'l Public Cl Other n Delta Depth of Grout Seal Type of Grout -- I I Irrigation _Approx. Depth I I Eastern Surface Soul lnstalied by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material ii Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I. REPAIR/ADDITION I I DESTRUCTIONK iNo septic system permitted if public sewer is available within 200 lost.1 Installation will serve: Residence_L-1 Commercial— Other �� p11A '�7C—f":V 60 Number of living units: Z Number of bedrooms 2- Character Character of soll to a depth of 3 feet: 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 ❑ No. & Length of linea Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 regulstions of the San Joaquin County Home owner or licensed agent's signsture 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 warkman'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 scall forallrequired`In'spe'ctions. Complete drawing on reverse side. Signed Xn� C�{J �' w ---- Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by rh,, �. c'+-�tia,.n�,. _ Date Area 0-2- Pit 2Ph o►Grout Inspection by Date Final Inspection by Date 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 FEE AMOUNT DUE AMOUNT REMITTED K CEIVED BY PATE PERMIT'N0. INFO • EH 117 IREv. i e e EM 147617, 476 � ///