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x rAPPLICATION ,FOR PERM I T SAN JOAQUIN COUNTY-PUBL EAJJ L �TY PLIC HEALTH SERVICES ENVIRONMENTAL HEALT, I � TAL HEALTH DIVISION JOAQUIN, PHONE (209)468--3420 SPECIAL PERMITBOg'2o09, STOCKTON, CA 95201 L PERMIT EMPIRES 1 Xdi&R FROM DATE SU (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or Install the work herein described. Tl}fs,' application is made In eesgtliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. AJob Address ZL jaL `da tt'j t°g'174,e City >TkA-1 . I Lot Size/Acreage _OD Owner's Name 01 l_ r Address AJ Phone �30gs 1 Contractor Address License No. Phone TYPE OF WELL/PUMA: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK.--_ _ �.�SALISEWER LINESLD. PROP. LINE FOUNDATIONAGRI E WELL _,,—,,— 'OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA C UCTION SPECIFICATIONS '- Cl Industrial ❑ Open Bottom- ❑ Manteca Dia. of We xcavation Dia. of Well Casing [I Domestic/Private ❑ Gravel Pack El Trac Type of Casing_ Specifications Il Public 1.7 Other n Delta Depth of Grout Seal Type of Group_ _ I 1 Initiation _.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth q TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION PS. DESTRUCTION l I (No septic system permitted if public sewer is # available within 200 feet.} Installation will serve: Residence_,eL Commercial— Other *' Number of living units: _L_ Number of bedrooms�_ 4 Characier of sog to a depth of 3 feet: 4 !Water table depth SEPTIC TANK. ❑ T1rpa/Mf Capacity— l 7 p y No. Compartments PKG. TREATMENT Pei:-C] A,'/ �.T r� � 4d &' r Method of Disposal z Distance to nearest: 'Well - Foundation - L Property Line LEACHING UNE ❑ No. 6 Lengtfikof lines Total length/size FILTER ,BED ❑ Distance to nerest >-- Wein FoundationProperty Line �1 t . , SEEPAGE PITS Depth 5 . Size_�� tr� �Nuinber # SUMPS LI Distance to merest:f Well--4 Foundation y_ Property Line DISPOSAL PONDS ❑ f ,i�a. "� "'� : A. �. 'I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county`ordinances, stele laws, and rules and regufationsfof the San Joaquin County Homs 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 shell not employ any person in:auch-msnner•as to become subject to workman's compensation Iaws of California.-'',Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performence-oUthe. work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicanNinust call for all required insmatons. Complete drawing on reverse side. `+ !! Signed �. Ay 4 Title: LL �. Date FOR DEPARTMENT USE ONLY Application Accepted by- Date r Z Area ' a - 77 Pit or Grout,lnspection b t " ' y date r Final Inspection by Date Additional Comments: Vtl SAN JOAQUTN COUNTY-PUBLIC HEALTH SERVICES MVvicesIR21MENT HEALTH DIVISION Applicant - Return all copies to: San squin County Public Health Ser • 445 N San Health Permit2009 � A� PERMIT 445 h Saa Joaquin, O Box 2009; L FEE INFO AMOUNT DUE AMOUNT R MITTEDCA5 RECE.IVED,BY D E ?ERMIT'NO..