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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONIdENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE S (Complete in Triplicate) Application is hereby made to Sao Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. /J�' A/ Job Address 7_5o, City &1 � t Size/Acreage .G 't7wner'i Nama "--� //6I Address Phone 19"If 07- Contractor r' i"irdr ess ��-�Q License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION C1 Out of Service Well 0 PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 0 DISTANCE TO NEAREST- SEPTIC TANK f SEWER LINES O�A ,F,I_� PROP. LINEI � /S UNDATION �AGRICULTURE WELL H LLC PITS/SUMPS �-- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ia. of Well Casing Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing ru pecificationa V1 Publicn it Other n Delta Depth of Grout Seal 1 Type of Grout I I Irrigation A D Approx. Depth I 1 Eastern Surface Seal installed by Repair Work Done U Type of Pump H.P. S State Work Done Well Destruction O Well Diameter Sealing Material i Depth A ` Depth Filler Material i Depth "' 1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted i1 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 fast: Water table depth• SEPTIC TANK O Type/Mfg _ Capacity No. Compartments PKG. TREATMENT PLT.0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. b Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: . Well Foundation Property Line DISPOSAL PONDS 0 1 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 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 applicant s i tions. Complete drawing on reverse low Signed X Title: 4-1 Date: r Tt_ DEPARTMENT USE QNLYtiD- l ApplApplicationion Accepted byData��, , Ara, Q Z L Pit rout tion by Date b yL fins! Inspection by ./ /' Data Add'rtlonalComrr+ants: - 1 Iyff'-/ d� /Ell 1-Spm'' lrJ�'� Applicant - Return all copLe to: San Joaquin County Public Hea th Services Xe - " rre$ A ,n 5-0 445 Health Permit/Services it 445 N San'doaquin, :P O Box 2009, Stkn, CA 95201 FEEi AMOUNT DUE AMOUNT REMITTED INFO EIVED by O TE PERM17'N0. SH _ W n K Lxoda&44re tElNii.24(REV.1/a5) 'T I -5 t:i (� I /