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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES f ENVIRONMENTAL HEALTH DIVISION !� 445 N SAN JOAQUIN, PHONE (209)468-3420V (� P 0 SOS 2009, STOCKTON, CA -96201 r v� W �pctt.c ()VA" ' tArA � ,PERMIT _EXPIRES t YEAR FROM DATE ISSUID NO (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to construct and/or inetall the work herein describ Thi, application is made in compliance with San Joaquin County Ordtnence No. 5h9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Servicers. r )(Job Address ..�v '` + ��V� City�r "—" Lot 61ze/Acreage �� d J[ Owner's Name r ddress hone ontfactof "' `,V Address-4" License No. Phone � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION 0 Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 01 FLD. PROP. LINE FOUNDATION RE WELL LL PITS/SUMPS INTENDED USE TYPE ELL PROBLEM AREA TRUCTION SPECIFICATIONS �` 03 fl Industrial in Bottom ❑ Mant Dia. of Well Excavation Dia. of Well Casing F1 Domestic/PrivateL, Gravel Pack racy Type of Casing_, __ Specifications VI Public I-lbther F1 Delta Depth of Grout SealType of Grout I I kri0atiort _.Approx. Depth~ 1 I Eastern Surface Soul Installed by r Repair Work Done U Type of Pump —______ _ _ H.P. State Work Done _ Well Destruction ❑ Well Diameter —_______ Sealing Material 6 Depth Depth Filler Wterial & Depth eft TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIR/ADDITION f l DESTRUCTIONiJoNoseptic system permitted if public sewer is r" i vailable within 200 foot,) Installation will serve: Residence �._ Commercial,.,,_.,. Other H Number of living units: Numbir'Cf bedrooms Character of $oil to a depth of 3 feet: Water table depth SEPTIC TANK © Type/Mfg __ �T'Capacity_ _ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Founds ion Property Line LEACHING LINE ❑ No. & Length of linea ' Total length/size FILTER BED n Distance to nearest:; q Well ` Foundation Property Line t SEEPAGE PITS 11 Depth Size Number y SUMPS LI Distance to nearest: Well Foundation Property Lina DISPOSAL PONDS ❑ I hereby certify that I have prepared this application end that the work will be done in accordance with San Joaquin county ordinances, state laws, and rulis 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: "I certify that i he 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" st call for all r ire spection Co fete dr on reverse side. ' ignad XTitla: Date: F DEPARTMENT USE ONLY r Application Accepted by _ (:, Date ►_-s � Area al- Pit Pit or Grout inspection by Data---------r— Final Inspection by Data f? ? ' Additional Comments: 0 1 Applicant - Return all copies to: San Joaquin County Public Health Services P Environmental Health Permit/Services Pi 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUN pUE AMOUNT REMITTED CASH RECEIVED.BY - DATE PERMIT'N0. I • EH 13-24 fazEv.��nsi � f EM t�.m