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APPLICATION FOR PERMIT4i ,S . SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION /) 1601 E. HAZELTON AVE. , PHONE (209)468-3420 X10 \CA-- I�S - ® 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. `-,, Y\Job Address Asn <Pr�„�.1 IZ�� City �� of Size/Acreage Owner's Name f` �5 Address t,/-X:!23- V 94�6aNO2 ,is Phone t Contractor Address License No. Phone WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ �OTHER ❑ Mon 1DISTANCE TO NEAREST: S NK SEWER LINES DISPOSAL FIPROP. LINE FOUNDATION AGRICULTURE WELL R WELLPITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLE TRUCTION SPECIFICATIONS n Industrial O Open Bottom O a 1 . Well Excavation Dia. of Well Casing CI Domestic/Private O Gravel Pa O Tracy Type of Casin Specifications I'I Public er n Delta Depth of Grout Seal Type of Grout 110, I I Irrigation _.Approx. Depth ( I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done ,n Well Destruction O Well Diameter Sealing Material & Depth u( Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I / I rr system permitted it public sewer is ED ithin 200 feet.) Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms-Permit MaY have expir d Witihou r Character of soil to a depth of 3 feet: 91 ater table depth SEPTIC TANK O Type/Mfg -W1 Ilk U16#11lukAti 1 Or Inspected. Compartments PKG. TREATMENT PLT. O by -wiroum.. ,[ � ��It� ��,jorpethod of Disposal (�_ Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line T SEEPAGE PITS 11 Depth Size a Number SUMPS LI Distance to nearest: Well Foundation 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 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 sub-contracting signature certifies the following: "1 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 mus al a required inspections. Complete drawing on reverse side. Signed Xyc �e Title: � � 1/�rc7„` ,�! Date: 11 11 FOR DEPARTMENT USE ONLY Application Accepted by W Date ` 2O 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. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIV/E'�D BY DATE /� PERMIT'NO. + EM 13.21 IREV.rinse 1� 0' C>� W)S K (D, �`7r EH 11.26 11 WW l 1• (�[ O