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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 PAYMENT (209) 468-3447 RECEIVED (Complete in Triplicate) OC 10 Application is hereby made to San Joaquin County for a permit to construct and/or install the wo � �eC�� Nk�i application Is mad: in ce�liance with San Joaquin County Ordinance No. 549 and 1862 and the EtlV1RQf�M�i TAI pIV3SS�lON Joaquin County Public Health Services. k t 0nJob Address �I City Lot size/Acreage 1'1 o u S�iivriar's�F��ms Ii / ' Address cPhone - 101 . 7759 ScottS VallevI Ste . 101 , Scotts Valley Coriffacio`r 3 - 16 16 "P_-,�Yc res License No.5-7-5-6-6.2—Phone -7 511 TYPE OF WELL/PUMP: I�' NEW WELL ❑ WELL REPLACEMENT F.) DESTRUCTION CI out of Service well Cl X PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ a P P r o h e OTHER M Monitoring well C.3 DIST/CINCf''r0 NEAREST: SEPTIC TANK 0 f t . .- SEWER LINES 0 ft , DISPOSAL FLD- 0 f PROP. LINE FOS NDATION f J. _ AGRICULTURE WELL ILI L•OTHER WELL PITS/SUMPS Q -f t . G --�INTfNDED-USE' '-TYPE OF-WELL- -PROBLEM AREA—CONSTRUCTION SPECIFICATIONS k1 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing O Y A t t dU b6n5'estic/Private Cl Gravel Pack 0 Tracy Type of Casing . Specifications 1w M public IXl Other L3 Delta Depth of Grout Seal Type of Grout M Irrioation I.4�1.Approx. Depth ❑ Eastern Surface Soul Installed by Repair Work Done L3 Type of Pump H.P. State Work Done_ Well Destruction O Weil Diameter Sealing Material & Depth Dep. Filler Material & Depth TYPE OF SEPTIC WORK: NEWINSTALLATION 0 REP AIRIADDITION M DESTRUCTION G (No septic system permitted if public sewer is a1- available within 200 feet.) Installation will serve: Residence— Commercial___- Other Number of living units: A• Number of bedrooms i Character of Boli to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, Cl ��. Method of Disposal. Distance to nearest: Well Foundation Property Line .F LEACHING LINE L, iNo. 8 Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Wel Foundation Property Line DISPOSAL PONDS a SII. "l FeWy csnify that-1 have grepbred this application and that the work will be done in accordance with San Joaquin county ordinances,state taws, and "i rules and regulations of the San Joaquin County ! Home owner or licensed agents 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 fotlowing: "I sonify`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 t call f r 11 Ir co required ins ons. Complete drawing on reverse side. Signed Title: Data: 0 F iIIP FOR DEPARTMENT USE ONLY G Application Accepted by Date, �' l 47 Araa T.Pit or Grout Inspection by Date Final Inspection by Additional Comments - Applicant - Return all copiers to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRON14ENTAL HEALTH DIVISION PERMIT/SERVICES I: 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. . I"t3-24 tat v.,.n s, 7�i Ick/S coo 90_ 7y " �� !�