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�'- PL CATION FOR `PERMIT k .;. OAQUIN COUNTY PUBLIC HEALTH SERVICES ,b\$ a \1 'ENVIRONMENTAL HEALTH DIVISION $ , 445 N SAN JOAQUIN, PHONE {209)468-3420 P O BOX 2009, STOCKTON, CA 95201 \9 =IRES YEAR FRAM-DATE U .PERMIT _ ,. (Complete in Triplicate) Applicatio is ereby made to San Joaquin County for a permit to construct and/or install the work herein described. This applicatio is a in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin C ty Public Health Services. �i �O f City JjC� du Lot Size/Acreage Job Address O 1 0" V t 14 �C#f'i�lFt�Y .- {� Ei — Phone Owner's Name Address _ Contractor Address License No. Phone i PE OF WELL/PUMP: NEW WELL Cl WELL REPLACEMENT Cl DESTRUCTION 0 Out of Service Well ❑ fPUMP INSTALLATION ❑= SYSTEM REPAIR C1OTHER El monitoring Well n + DISTANCE TO NEA SEPTIC TANK` SEWER LINES DISPOSAL FLD. PROP. LINE FOU AGRICULTURE WELL OTHER WELL PIT !SUMPS INTENDED USE TYPE OF WELL EM AREA CONSTRUCTION SPECIFICATIONS L] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r • Type Specifications. [ Cl Domestic!Private ❑ Gravel Pack ❑ Tracy o - t III Public (.1 Other F1 Delta Depth of Grout Sea Type of Grout I I Irrigation w Approx}Depth 1 I Eastern Surface Seel Installed by r Repair Work Done ;U-- :Type of Pump H.P. State Work Done_ woo Destruction ❑ Well Diameter. Sealing material i Depth Depth. Filler Material & Depth V TYPE OF SEPTIC WORK: NEW INSTALLATION ! REPAIRlAODITION I i DESTRUCTION I I INo septic system permitted if public sower is available within 200_ teal.) Installation will some: RasiCenca JG. ,Commercial— Other—, � Number of living units: Number ofr ' X35 W Character of soil to,a de�pthh f 3 feet 2 . _ ater table depth ! k SEPTIC TANK LW TYps/Mfg __C g �-- �'�Crt'�'S— Capacity g -Ahlo. Compartments PKG. TREATMENT.F!LT. b- k Method of Dj I _ Y Distance to nearest: Well N # 'F-oundatiun� ropertY Line _ LEACHING LINENo. $ Length of lines Total le ihlsiza FILTER BED W Distance to nearest: Well p %undation _1Property Line 4' C Numbgr SEEPAGE PITS 11 iDepth _.,, 1a��Sire '{ J� SUMP$ ' CI 'Distance to nearest: Well _� ."dation lajL - roperty Line POSAL PONDS ❑ I reby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and t r s and regulations of the San Joaquin county on►s 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 mploy any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-conlrecting 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 call for all requir in coons. Complete drawing on reverse side. fl- 3 I� 3 Title:n . Date: Signed.. FOR DEPARTMENT USE ONLY XAppliGstlon Accepted by Date Ar L ' or Grout Inspection by Date 7 h Final Inspection by T DIte Additbti�Comments: a� L j 4-. Applicant - Retu'rn all copies to: San Joaquin County Public Hem th Services Environmental Health Permit/Services 445 N San Joaquin,YP O Box 2009, Stkn, CA 95201 F AMOUNT DUE AMOUNT REMITTED ~CASH RECEIVED BY DATE PERMIT'NO. � INF 11 . EH 13.14(REV.1/n 5) �-�-41 ��/ � �'V/� EH 14.76 s