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- APPLICATION FOR PERMIT PAYMENT SAN J�MdAQUIN COUNTY PUBLIC HEALTH VICES RECEIVED ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 FEB 10 IM P O BOX 2009, STOCKTON, CA 95201 SAN JOAQUIN COUNTY PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PUBLIC HEALTH SEP.VICES (Complete in Triplicate) ENVIRONMENTALHEALTH DIVISIO;J Application is hereby Slade 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 Bo. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address City SSC-K-V Lot Size/Acreage C'tA"r-00 I Po 4 x" so0o� Ovmer'sName Rn0 Address Sf�1� MCIVrR Phone C lf] Solt 6,c(,nor�tcyl Contractor_c?VVI US _ Address i License No 5�s�e0� hone_ TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION ❑ Out of ce W PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -S-Z� I'T- DISPOSAL FLO. '-- PROP. LIN FOUNDATION AGRICULTURE WELL OTHER WELLL_ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1 pY�omestk; riv a ;SQ_Graysl Pack ❑ Tracy Type of Casing SCfA 40 J C— Specifications 11 Public n of (l Delta Depth of Grout Seal SZ> Type of Grout �fcNTonl'rE I I Irrigation '7Q?Lx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ ^� Well Destruction ❑ Well Diameter Sealing Material L Depth f� Depth F Filler Material 4 Depth V , TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal knee to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines Total len Al FILTER BED ❑ Distance to nearest: Well Fou Property Line SEEPAGE PITS I I Depth Size Number SUMPS tants to nearest: Well Foundation Property Line DISPOSAL PON ❑ 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 Homs ownsr 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 subcontracting 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 applicaO cast Call for I required inspections. Complete drawing on reverse side. Signed X `\ - - Title: 4 g< �©6A n,� Date: fc q3 FOR DEPARTMENT USE ONLY Application Accepted by Date 1 Area c Ph or Grout Inspection by of Alic Day"43— Final Inspection by Dale 5'o' L Additional Comments: 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 CASH RECEIVED BY DATE PERMIT'NO. INFO EH 13-24 fREV.r/a m)AIM EH 14-X