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APPLICATION FOR PbiUdl'1' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOR 2009 , STOCKTON, CA 95201 /P- (209) P(209) 468-3447 PERI(IT EXPIRES I YEAR PROM 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. Job Address 'I 7.5 S /0. D i 1-> City LSD Lot Size/ creage Owner's Name11/'iA✓h Address (, 3 S.3 �. ��lP.t=Y �.�� Phone 7 Contractor Address 7i1/ r License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR D 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 t• 11 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout } CJ Irrigation _ Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material i Depth - Depth Piller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION,f REPAIR/ADDITION 0 DESTRUCTION G INo septic system permitted it public sewer is / available within 200 teat.) Installation will serve: Residence ✓ Commercial _ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: i-./-A/ /0,4r+1 Water table depth SEPTIC TANK 2r' Type/Mfg _L'-� - fJ9- Capacity 1 i- n No. Compartments J PKG. TREATMENT PLT, 0 Method of Disposal Distance to nearest: Well /t( Foundation %!' Property Line LEACHING LINE L No. & Length o1 lines _ 2 - '?S Total length/size / 7^' FILTER BED 1-1 Distance to nearest: Well Foundation Property Line �F SEEPAGE PITS Ik Depth ZS ' Size <)lo Number SUMPS LI Distance to nearest: Well /.S6 Foundation //G' Property Line �3(' DISPOSAL PONDS Cl 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 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 must call for alt required inspections. Complete drawing on reverse side. Signed X� f// Title: Date: 4.2- _z-L' FOR DEPARTMENT USE ONLY Application Accepted by � �lc� RCI. Date d`14(L— l tJ Area ! 3 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. EH 13-24(REV.riper c�c> vv