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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALM-89k#'�S ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 wit ", CJI 4Z:L.1 P O BOX 2009, STOCKTON, CA 95201 O . v4 g- PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made,to San Joaquin 0ounty 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 �/3 1. /r S- &t-t R 'as City -Sw✓ Lotze/Acreage Owner's Name DLX R A/S Address Sa.>"x Phone Contractor mak ' C.• OSIS r/. Address A631y b E. F/o x ia/a License No. ,93 /40 Phone ®� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well ❑ PUMP NST AL .TION O SYSTEM REPAIR O OTHER O Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC NK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATI AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL ROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial O Open Bottom O ca Dia. of Well Excavation Dia. of=Well Casing Cl Domestic/Private ❑ Gravel Pack O Tracy Type of Casing Specifications f'1 Public Cl Other n Delta De f Grout Seal Type of Grout I I Irrigatiori. �.Approx. Depth I I Eastern Surface Sea lied by Repair Work Done, U Type of Pump H.P. ate Work Done Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK:-NEW INSTALLATION l 1 REPAIR/ADDITION 1 1. :DESTRUCTION INo septic system permitted it public sewer is available within 200 feet.) 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 SEPTIC TANK ❑ Type/Mfg Capacity_ T No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE O No. & Length of lines Total length/size FILTER BED O Distance to nearest: Wall Foundation Property Line SEEPAGE PITS 11 Depth Size _ 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 ddhe 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 cerfify that in the'performarice 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: "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 all required inspections. Complete drawing on reverse side. Signed X Title: - Date: ` R DEPARTMENT USE ONLY q -- Application Accepted by �� Date `S 31-9 k Area_fit i Pit or Grout Inspection by Date Final Inspection by >Z" Date l (,r) L 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 CASH RECEIVED BY DATE PERMIT'NO.