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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 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application Is hereby made to San 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. �r Job Address 7 TiiE l ��1�/i City -`fnZ t.ot t31ze/Acreage Owner's No Address L Phone r i R 6abs lva �r�$Z 1� Contractor Address License No Phone TYPE OF W L/PUM NEW WELL ❑ WELL REPLACEM04T 11 DESTRUCTION O Out of Service Well PUMP INSTALLATION O - SVSTEM REPAIR ❑ OTHER ❑ Monitoring Well El 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 n Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 171 Domestic/Private Cl Gravel Pack O Tracy Type of Casing_ Specifications I'I Public 1-1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by \ Repair Work Done U Type of Pump H.P. State Work Done_ V Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 lost.) InaaNation wiq serve: Residence— Commsrclapt— Other�` t T t t V_ Nu6*w of living units: Q_ Numberof rooms Ch*Ktar Of SON to a depth of 3 feet: Water table depth SEPTIC TANK D Type/Mfg CapacityL�-- No. Compartments PKG. TREATMENT PLt.0 Method of Disposal Distance to nearest: Well 110 Foundation _ 1 b Property Line U LEACHING LINE Qf No. 6 Length of lures) Total length/size FILTER BED O Distance to ralarest: Well (' Foundation -1 �' Property Line ;F SEEPAGE PITS ?.r Depth 11 Size _ Number 4 SUMPS LI Distance to nNrest: Well. / Foundation property Line _ [' DISPOSAL PONDS ❑ I hereby Certify lhat 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 sAy parson in such manner as to become subject tow orkm •compensation laws of California." Contractor's hiring or sub-contracting signature cenifist the following:"I certify that in the performance of the for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant t cell for an req Ins tans. Co ate drawing onreverseside. Sip Title: /� --� Date: �-91 3 FOR DEPARTMENT USE ONLY 2 1 Appikation Accepted by Date `� S J Area Zf1 Ph or Grout Intpactbh by Date Final Inspection by Date AA Addhional Comments: r /P 2 W 7 0e_ 0✓Cr' sQ/A t'b.pf Q , Applicant - Return all copies to: San Joaquin County Public Health ServicesoaAwr/htDt'A�d 4 01opyw- -6be jA_i5 Environmental Health Permit/Services L, ✓J 445 N Sae Joaquin, P 0 Box 2009, Stkn, CA 95201 Kwl FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED SY DATE PERMIT'N0. INFO CASH EH 13-24(REV.I/AS) 5 ,y/ems_ I (�/A{ay Q EH 11•� 1I ,- �/T7 J' 7