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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY- PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 Pg MIT MIRES— 1 YEAR FROM DATE ISt5U (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 rade in compliance with San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. c Job Address %FO r- Y City S Lot Size/Acreage 4 r, .e - ' ��\ : '? Phone 3 d 00 # Owner's Name 'Address /. Contractor t w Address( License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ ELL REPLACEMENT ❑ DESTRUCTION ❑ Out ofnS.ervice Well ❑ PUMP INSTALLATION ❑ /SYEMREPAIR 0 OTHER ❑ J' ��. -At7 ) W�DISTANCE TO NEAREST: SEPTIC_TANK SEWER INDISPOSAL FLD, PROP"... -. _ - . ...-. _FOUNDATION AGRICU LL OTHER WELL PITS/SUMPS t INTENDED,USE ! TYPE OF WELL' PROBLEM AR. CONSTRUCTION SPECIFICA7lONS t CI Industriai C] Open Bottom " ti' C1 Ilhantec Dia- of Well Excavation Dia. of Wel[Casing - F t, Spe•cifcations -4 D Domestic/Private Cl Gravel Pack - - ,C7-Trac =Type of Casing i I'1 Public 1-1 Other fl to Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth Eastern Surface Seal Installed by — --- Repair Work Done_ II Type of Pump H-P. State Work Done Well Destruction ❑ Well Diameter Seal Material & Depth i •__ ,. r Depth Filler Material & Depth {t ' 'TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION 1 1 DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet,) 4 ' t (installation will serve: Residence— Commercial✓Other � (� Number of living units: Number of bedrooms o 1� Character of soil to a depth of 3 feet: Water table depth f SEPTIC TANK ❑ Type/Mfg v Capacity-.4VI1910 No. Compartments PKG. TREATMENT PLT. Cl Method of Dispo l Distance to nearest: Well 13 X Foundation Property Line _J- t i i LEACHING LINE ❑ No. & Length of lines S Total length/size 1 I ¢ FILTER BED Cl Distance to nearest: Well FoundationProper ine SEEPAGE PITS 11 Depth Size ;Nam er SUMPS Ll Distance to neo est: Well N o kne Foundation Property Line DISPOSAL PONDS C1 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 fegulations of the San Joaquin County {k�`�" i 1 = 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 shat!not I` employ any person in such manner as-to become subject to workman's compensation laws of Calif ornii.`',,Contractor'e hiring or sub-contracting 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 compansa- tion laws of California." S The applican must call for =require Inspections. Complete drawing on reverse side. Signed XTitle: O&AOIA44Date: - f r ` 'COR DEPARTMENT USE ONLY w G Y_Cw�, '1 s �. P Date � Area- , E Application Accepted by:_ - . J 3 f Pit or Grout inspection by �Pats. t. Fina jngpection-by Data�4_ k ��s -- . (o r`g1,1 �,q 3 w e s s h { Additional Comments: I i } „yu k. kJ Applicant Return copies to: San Joaquin County Public Health c, 1 Services, Environmental Health Permit/Service 1601 E. Hazelton Ave., P-0 Boxi2009, Stocktton, P 95201 t �.x { >rx ! FEE MOUNT DUE AMOUNT REMITTED CASH RCEIVED BY DATE :•"j PERMIT NO.�" INFO �r +EM 13-2s tREv.t i n 5] �� , U ."Ye 107 EH:1.28r �_� i