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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Vl11 ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCHTON, CA 95201 (209) 468-3447 4 PEMIT�E%PIRES 1 YEAR OR-OM 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 comiliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin Cmty Public Health Services. Job Address Lf 47 A QE City 57k& Lot Size/Acreage /SdX 1-7S_ Ownet's Name --R16MAf'D Address Phone i;* -� Contractor iy .EJ 4,&eD Address � ,_ AD�tl� .e�-.�t/� License No, �7G Phone r.3 7 TYPE OF WELL/PUMP: l+ NEW WEL WELL REPLACE NT [ } DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION' SYSTE EP AIR ❑ OTHER ❑ Monitoring Well 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION GRICULTVdWELL OTHER WELL PITS/SUMPS .� _ INTENDED USE TYPE OF WE2Easiern CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open BottomDia. of Well Excavation Dia. of Well Casing 2S U Domestic/Private ❑ Gravel PackType of Casing Specifications M Public C] Otherepth of Grout Seal Type of Grout CI Irrigation ApproK, D `a_ S ace Seal Installed by Repair Work Done U T ype of Pump State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth DeptW Filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION DESTRUCTION C1 INo septic system permitted if public sewer is 1. r_ available within 200 feet-1 `Inllation will serve: ResidenceCommercial Other Pu�LJc 41AA t � sta Number of living units:._L 1�wNumber.of bedrooms _ Character of soil to a depth of;. CL feet;, _ Water table depth SEPTIC TANK. ❑ ,Ty{pilMfg � �Y1 S Z"ial� _. _ Capacity No, Compartments PKG, TREATMENT PLT. Method of Disposal f Distance to nearest: Well Foundation Property Line LEACHING-LINE A---fk(•-No. & Length of lines _rr2_"�� ,. Total length/sirs 4, FILTER BED n� Distance to nearest: Well AJIAFoundation-- 7,e . •Property Line-�S , SEEPAGE PITS`� Depth �Size X 12� �� Number SUMPS X Distance to nearest: Well A11A Foundation Property Line -5- r # DISPOSAL-PONDS- ❑ I hereby comity that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and` d rules and regulations of the.San Joaquin County I 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 L° employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature cemifies the following; "I cekify'that in-the performance of Me-work for which this permit-is-issuid-1 ihail employ.peritons subject to workman's compensa- tion laws of California." . - f The applicant must calf for all required inspections. Complete drawing on 4everse side, _ { SignedT! { .?(� � 't a _(� = _osis: - DEPARTMENT USE ONLY Application Accepted by Date — Area e Pit or Grout Inspection by Date Final Inspection by Dats lei f - Additional Comments: _ Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2008,- STOCKTON, CA 85201 FEE INFO AMOUNT DUE AMOUNT AEMtrTEp CASH AEGEIVEp BY DATE PERMIT'N0. •. E31;baa i