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APPLICATICN 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 ISSUED (Complete in Triplicate) Application is hereby rade 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 ourt Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. _ul �l� f icpnridn� t ic(LS q(nf T'1 411+l f_,] 4-yen < _11_A_ <�, Hrri Lot Size/Acreage Owner's Name ARco':�I76tALAf-b CDWQnL1- Address O t U Phone Contractor o () j� '•Z' D1_• �` I Address 1'• C7 B 13 Box (3 License No. Phone TYPE OF WELL/PUMP: W WELL WELL REPLACEMENT Fl DESTRUCTION C Out of Service Well D DATE PUMP INSTALLATIO O SYSTE REPAIR C OTHER C Monitoring Well 0 1 DISTANCE TO NEAREST: SEPTIC TANK != SEWER LINES ICJ DISPOSAL FLDX��_ PROP. LINEA2a FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing Z nGL1 F] Domestic/ Private Cl Gravel Pack C Tracy Type of Casing_'PUL Specifications i'1 Public El Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation \\ — Approx. Depth I I Eastern Surface Seal Installed by C` Repair Work Done U Type of Pump H. P. State Work Done _ Well Destruction O Well Diameter Sealing Material L Depth Depth Tiller Material L Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I 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 Number of living units: Number of bedrooms Character of sod to a depth of 3 feet: Water table depth SEPTIC TANK p Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No. b Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C 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 rtj4st_pall for all regyirpd inspections. Complete drawing on reverse side. Signed On F,!" Application Accepted by Pit or Grout Inspection by Additional Comments: __� ol Title: �� S/ Date: �Gc7 FOR DEPARTMENT USE ONLY / COMM - Data -� /l - Area v r Date Final Inspection by Applicant - RetuYCK all copies to: San Joaquin County Public Health Services��UUt Environmental Health Permit/Services 4 445 N San Joaquin, P O Box 2009, Stkn, CA 952 • EH 1344 (REV. r i n s. EH •2a Date FEE INFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT NO. cul