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� Y APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) , Application to hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in coatpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address �J D ' • ' "� City Lot Size/Acreage c ^C /1/' `/� /� VP .5-157 Owner's Na SEPI' Address ��5 /�KOs+ Phone /.3� ��' �j Z Contractor Address ( z7 r License Nd! /33 Phone ✓/ �� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER ❑ Monitoring Well ❑ 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 I-) Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing El Domestic/Private n Gravel Pack ❑ Tracy Type of Casing_ Specifications ("1\ Il Public fl Other fl Delta Depth of Grout Seal Type of Grout �J I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction D We" Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITIONDESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial X Other Number of living units: Number of bed oo s Charsaw of soli to a depth of 3 feet: 7;Z Water table depth SEPTIC TANK. p Type/Mfg Capacity�!Y No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well Foundation Property Lino LEACHING LINE Ll No. 8 Length of lines a Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS If Depth Size l Number 1. ' SUMPS LI Distance to nearest: Well a� Foundation r �� Property Line 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 owhor or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to workmen's compensation laws of California."Contractor's hiring or sub-contracting signstur 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 lawn of California." The applies t rtwst for 911 required spectio nsZZI— drawing on reverse side. Signed 7)9[vTTitle: Date: OR DEPARTMENT USE ONLY Application Accepted by Data Area a // PH or Grout Inspection by Date Final Inspection by �p De e Additional Comments: ( � 91— 9�IL Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P Box 2009, Stkn, CA 95201 FEE INFO AMOf/UNT DUE AMOUNT REMITTED CASH RECEIVED SY DATE st PERMIT N0. • EH 1 ..If1EV.river / Q �� - ��Te- 9�3C1 EH N>7 /