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APPLICATIOWFOR PERMIT i. 1� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOR 2009, STOCKTON, CA 95201 ED PMI RES 1 YEAR FR M D E 2 `i✓ �rL (Complete in Triplicate) Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This I applicstion 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. City p Lot Size/Acreage /'G Job Address I� Chef;_,. Address - Phone Owner's Name �_ WMA Contractordress �rLicense No.,�� Phone TYPE OF WELLIPUMP: WELL ❑ WELL REPLACEMENT.❑ DESTRUCTION ❑ Out of Well PUMP WSTALLATION.,.❑ SYSTEM REPAIR E1 OTHER ❑ r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION ' "AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F, Industrial ❑ Open Bottom ❑ MaAteca Dia. of Well Excavation Dia. of Well Casing Specifications P Domestic/Private ❑ Gravel Pack 0 Tracyyf Type of Casing . I'I Public (:1 Other Cl Delta k Depth of Grout Seal Type of Grout i I I Irrigation —.Approx. Depth I I Eastern r Surface Seal Installed by Repair Work Done L7 Type of Pump HSP. State Work Done Weil Destruction ❑ Well Diameter _�__,_� -Seali.ng;Material & Depth h Depthi � I TYPE Of SEPTIC WORK: NEW INSTALLATION l' REPAIR/ADDITION I I DESTRUCTION I 1 INo septic-system permitted if public sewer is v 3 a C available within 200 feet.) finstallation will serve: Residence x Commeicial Other e Number of living units: Number of b�l oma ' – s �. 26 Character of soil to a depth of 3 feet: —Water table depth SEPTIC TANK. 1R Type/Mfg Capacity 6 No. Compartments PKG. TREATMENT PLT. ❑ t r Method of Disposal Distance to nearest: fl Well S� Foundation' Property Line LEACHING LINE No. & Length of dines Total length/size 2 FILTER BED 0 Distance to nearest: ;Well --_Foundation �f�r Property Line y SEEPAGE PITS Depth 25_ sill Number SUMPS LI Distance to near l:' Well 11e) Foundation /0 Property Line . DISPOSAL PONDS 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 C6unty '` 4 Home owner or licensed agent's signature„certifies the following:."I certify that in the performance of the work for which this pariah is issued, I shall not employ any person in such manner as to become subject to workriian's compensation laws of California.” Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the pertormance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." i The applican t tail for I qu' d inspections. Complete drawing on reverse de l Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area --- �. or Grout Inspection by ate "� Fines Inspection by Date Additional Comments: I 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 AMOUNT DUE AMOUNT REMITTED CK 4 CASH RECEIVED BY DATE PERMIT'NO. INFO • CH13-24IREV.iinas EH 142E