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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, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby lade to San Joaquin County for A permit to construct and/or install the vork herein described. This application is made in coetpliance with Han Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address r7 /_33 .E, #W y ;--f- City L/0/D,-n.l Lot Size/Acreage /O AG nt�L Owner's Name EP-A AIX 19 e tfES Address Phone Contractor E4A:YD WOOD Address "7 ,V, A License No. y1�3-7G Phone S''3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well O 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 FI Industrial O Open Bottom O Manteca Dia. of Well Excavation Dis. of Well Casing f 1 Domestic/Private O Gravel Pack ❑ Tracy Type of Casing_ Specifications 11 Public Cl Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation — Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump H.P. _ State Work Done _ Wait Destruction O W&W Dismster Sealing Material i Depth Depth filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION4 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence Z Commercial_ Other Number of 4ving units: f Number of bedrooms Character of toll to a depth of 3 feet: VA L.t D t/ Water table depth SEPTIC TANK O Type/Mfg P E-i- Capacity /160 0 No. Compartments Z PKG. TREATMENT PLT. Cl Method of Disposal Distance to nedrest: Well /AOt Foundation j Property Lin* /md LEACHING LINE Lor No. 6 Length of lines 2-- gs Total length/sl:e FILTER BED n Distance to nearest: Well /DEP* Foundation /m i/- Property Line ¢10" SEEPAGE PITS Depth 7 S Sim _�� Number SUMPS LI Distance to nearest: Well /3D ,A- Foundation /Od Property Line p- DISPOSAL PONDS O 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 perfo0hance of the Work for which this permit is issued, I shall not employ env person in such manner is to becomb subject to workman's compbhsation laws of Cilifornid." 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 compenss tion lewd of California." The applicant must call for aN requited ins tions. Complete drawing on reverse side. Signed X c 1�� Title: C Date: FOR DEPARTMENT USE ONLY Application Accepted by Data Ab Z- Area Ph or Grout Inspection by Date/ 1 2 / Final Inspection by Date OH( 2 Additional Comments:mmComments:le' t e `-t Applicant - Return all copies to: San Joaquin County Public Health Services Bnvironmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, OA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED by DATE PERMIT NO. . EM 17-N IaEV.r,nsr �� / D EH 1 4.38 /V /