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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468—Z4-4-7 34� RDATE ISUM (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 ccmtplisnce with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address AJ 5//U City '� Lot Size/Acreage Owner's Name 72i4C& Address Phone Contractor 140Y#7 _[ WadD Address ]' Al, 4POe ea �. License No. l4e=s]•-71- Phone 44-r-392 TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ 5Y5 M REPAIR ❑ OTHER ❑ Monitoring Well C7 t DISTANCE TO NEAREST; SEPTIC TANK SEWER L/NE DISPOSAL FLD. PROP. LINE t FOUNDATION AGRICUL WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELiL PROBL AR CONSTRUCTION SPECIFICATIONS �. L� industrial ❑ Open Bottom ❑ Manta Dia. of Well Excavation Dia, of Well Casing U Domestic/Private ❑`Gravel Pack ❑ Trac Type of Casing Specifications Cl Public 1.1 Other. CO) to Depths Grout Seal Type of Grout GI Irrigation Approx. Depth Eastern Surface Seal Installed by Repair Work Done U Typo of Pump H.P. State Work Done _ Well Destruction ❑ Welt Diameter Seal Material 4 Depth Depth' - Filler terial 4 Depth J TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION (No septic system permitted if public sewer is available within 200 test.) installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: - ' Water table depth (,A. SEPTIC TANK ❑, Typa/Mfg Capacity No. Compartments PKG.:TREATMENT PLT. ❑ , ' Method of Disposal o 1 Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Tolal length/size FILTER BED I Distance to nearest: Well Foundation Property Line ' i SEEPAGE PITS 11 Depth Size Number 1 SUMPS LI Distance to nearest, Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I hove 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 t0 become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature y certifies the following: "I cenify 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." z The applicant must call for all required inspections." plate drawing on reverse side. Signed X Title: Date: z- i FOR DEPARTMENT USE ONLY �+ Application Accepted by __JC4� 1.4_Iu ll' Date 'l Area i Pit or Grout Inspection by Date Final Inspection by Date Z Z Additional Comments: _ Applicant Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1 i ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICRS 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON. CA 95201 IEEECK AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"N0. EH 13•24 IREV.iiMsi r 6 EH t�•ZO ��