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APPLICATION FOR PERMIT A 7-1 AI i a r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOB 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 01,_53 Z. 4P,41Sr,Q2AJG Rb City L-42L Lot SitAcri' eeae l Owner's Name ACX Z>A e,5 G, ra. Address Phone Contractor AZe19i2 Address 7 Al, License No. "fz..t"•1.7e- Phone 3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 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 U10 n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing LJ Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications O Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout Cl Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done> `< Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material 4 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION X DESTRUCTION 0 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence 'f Commercial_ Other Number of living units: _J_ Number of bedrooms �i _ Character of soil to a depth of 3 feet: SAA/®x hgf_A.�K I-CdW Water table depth SEPTIC TANK O Type/Mfg C60 Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines — 7 S r Total length/size S FILTER BED ❑ Distance to nearest: Well Foundation /,v Property Line r ' Number X_� 2 la�U e®ems-lyr of SEEPAGE PITS I Depth �1a` � Sire SUMPS Distance to nearest: Well 100 Foundation /01 Property Line DISPOSAL PONDS ❑ 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 !r, 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, 1 shall nbt 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." r- The applicant must call for quired inspections, Complete drawing on reverse side. T SFS/ Signed __l� - �--. Title: - Date: < ,r... a FOR DEPARTMENT USE ONLY Application Accepted b:--\-.-> �-- Date f Area Pit or Grout Inspection by Date Final Inspection Date I-2 G Additional Comments: _ Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEE INFO AMO�UNT DUE AMOU�NT REMITTED CASH RECEIVED BY DdiceATE PERMIT'NO. . EH t�•24 IREV.I/n 51 .411 I."1 f t ,� �1-O(-) T 1qQ-33361 EH 11.26