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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOC%TON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby sada to Ban Joaquin County for a Permit to construct and/or install the vork herein described. This application in made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. r � /L Job Address 1`6/70 li/ � J � Cit Lot Size/Acreage C 4 2( Owner's Name A U),L l',- l-_ Address � �i�-� Phone 13�c7C7 3zz� E% s/vs Contrac fj? 1[3- , �t Ari; -��Address Q AN License No. Phone3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out or Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHEFiWELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation j Diay.�of Wall Casing FNT Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing SpTps'e�� rP l-_s�1 I"I Public I:1 Other fl Delta Depth of Grout Seal Ty 51t M1VED I I Irrigation _Approx. Depth 1 I Eastern Surface Saul Instilled by Il Repair Work Done O Type of Pump H.P. State Work Done _ Well Destruction ❑ Wall Diameter sealing Material a Depth _ •�2anll IN COON.Y Depth Filler Material s Depth - �Fi661C HEALTH SER�ICfS,ON TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION I I DESTRUCTION I I (No septic6WW Witpublic cower la available within 200 leat.l Installation will serve: Residence� Commercial_ Other Number of living units: / Number of Dome ? Character of soil to a depth of 3 1 . r�( _ ,Lr r�ti Water table depth (� SEPTIC TANK ❑ Type/Mfg ��"o� Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line cz LEACHING LINE No. 6 Length of lines �cL��/ Total length/size & x• FILTER BED ❑ Distance to nearest: Well oundation /0 y Property Line it SEEPAGE PITS Depth �S Sia 1�� Number r SUMPS LI Distance to nearest: Well _ Foundation. Property Line 15 DISPOSAL PONDS ❑ I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations o/ the Son 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 m call for �uj�r/pd Inspections. Complete drawing on reverse side. Signed X_ Title: '1/ Date: �•t — f l FOR DEPARTMENT USE ONLY Application Accepted by �` �D-�l_a - �/� Date Area 12- Grout 2- Grout Inspection by?� Date Final Inspection by ;a Date J Additional Comments: 4 Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CKCASH RECEIVED BY DATE PERMIT'NO. INF .• EM/22a1REV.iia llqo� EN .2m