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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCAKTON, CA 96201 (209) 468--&W31-1 ' R ?RQX DATE ISSUED (Complete in Triplicate) i AYplicatlon is hereby made:to Ban Joaquin County for a permit to construct and/or install the work herein described. This application is made in coWliance with San Joaquin County Ordinance No.. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. , �J Job Address ISD City„ rfL"'Lot Size/Acreage Owner's Name L f ._� rvL.=-Address 5545:30 � rVO�f�'T,Y� ��c.r�-fiPkfone Contractor Addres "Am License No. Phone YPE OF WELL/PUMP: I�i NEW WELL ID LL REPLACE NT ❑ DESTRUCTION C) out of Service We11 ❑ PUMPj.INSTALLATION ❑ SYSTE EPAIR 0 OTHER ❑ Monitoring Well 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE DISPOSAL FLD. PROP. LINE .i FOUNDATION AGRICULTUR WiLL OTHER WELT PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA C TRUCTION SPECIFICATIONS 17.1 Industrial 0 Open Bottom ❑ Manteca ia, Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Type o Casing Specifications M Public Cl Other ❑ Delta Depth of rout Seal Type of Grout 60 CJ Ifripation _-,. Approx, Depth 0 Eastern Surface S I installed by k Repair Work Done L] Type of Pump H State Work pone Well Destruction © Waif Dliameter &ling Material i epth r Depth Filler Material 4 De h YPE OF SEPTIC WORK: N£WI�INSTALLATION REPAIR/ADDITION ill DESTRUCTION LI (No septic system permitted if public sower is ✓✓// available within 200 feet.) 0 Installation will serve: Residence _ Commercial— Other { Number of living units: CNumber of bedrooms Character of soil to a depth of 3 feet: s Water table depth SEPTIC TANK O TV p /Mfg T �uC, L Capacity 12041 A'L-No. Compartments PKG. TREATMENT PLT. 11 ' Method of Ditiposal T` DistI r + ance to nearest: Well �_ Foundation � Property Line LEACHING ::: Cl No��8 Length of Lines /�� i�J(e Total length/sizerFILTER BEDf_7 Distance to nearest: Well� Foundation� Property Line _ SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS D g +. . 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 followin : " dy that in t a performance of the work for which this permit is issued, I shalt employ persons subject to workman's compensa• + tion laws of C rnla." j i The app' nt m all r +red ' ons. Complete drawing on reverse side. Si ns g Title: pate; FO DEPARTMENT USE ONLY Al: Application Accepted by Date 3 `1"9,� Area Pit or Grout Inspection by Date Final Inspection y Date f Additional Comments: I!' Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES f ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE INFO AMOUNT DVE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. . fM ��1, ' IREY.iiKe1 I '� 616 1ik/V� I.