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r APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O 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. Job Address C�5 L-1 City0"ti2 Lot Size/Acreage Owner's Name` Address Phone t Contract Address f ,License No.' Z�ZT�Phone TYPE OF WELL/PUMP: NEW WELL ❑ = WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service Well ❑ PUMP INSTALLATION ❑ ;+, SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION - AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL-..-' . PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Nlanse`ca'• Dia. of Well Excavation Dia. of Well Casing C1 Domestic/Private ❑ Gravel Pack ❑ Tracy �"� Type of Casing Specifications C1 Public CI Other n Delta N Depth of Grout Seal Type of Grout 1 I Irrigation —.Approx. Depth l I.Eastern "' '-. 'Surface Seal Installed by Repair Work Done L7 Type of Pump .,/H.P. •` - State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth FYller Material b Depth v r TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRJADDITION 1 I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial Other Number of living units: Number of Adrooms. Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. Type/Mfg da 4&A r ,Capacity No. Compartments ' PKG. TREATMENT PLT. ❑ / Method of Disposal- F Distance to nearest: Well Foundation", /t}_- Property Line c:s� LEACHING LINE >< No. & Length of lines T9tal length/sire FILTER BED 0 Distance to nearest: Well�Q_ Foundation l D Property Line µ { l � i SEEPAGE PITSDepth Size k Nymber ✓ -'_ _ - 'SUMPS L_ Distance to nearest: 'Well/fir Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and-ihat 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 fhe 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 sub-contracting signature I 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 mu 11 for all r fired 'nspections. Complete drawing on reverse side9 Signed XTitle: Date: FOR DEPARTMENT USE ONLY r rj Application Accepted by Date Area 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 Permit/Services 1601 E. Razelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK 11 RECEIVED BY DATE PERMIT'NO- INFyO CASH / EH 13-24 MEV.I/n sl •Iv �-' S 1 Z' �1 1 y1� ` EH 4428 1111 4