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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PHRMIT,„EXPIRES 1 YEAR_FRP-M DATE ISSUED (Complete in Triplicate) Application is hereby made.to San Joaquin County for a permit to construct end/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 C'y Lot Size/Acreage ,7,)- J( Owner's Name —y f �`� Address Z Phone ACContractorAddress License No. Phone TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION El SYSTEM REPAIR ❑ OTHER ❑ Monitor ng Well L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. P. LINE FOUNDATION AGRICULTURE WELL LL PITS/SUMPS INTENDED USE OF WELL PROBLEM AREA C TION SPECIFICATIONS M Industrial O Open Bottom n Dia. of Well Excavation Dia. of Well Casing V, Cl Domestic/Private ❑ Gravel Pack Tracy a of Casing Specifications I'I Public C7 ri Delta Depth o eal Type of Grout I I Irrigation _..Approx. Depth 1l Eastern Surface Saul Installed Repair one U Type of Pump H.P. State Warc Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIRIAODITION I I DESTRUCTION l INo septic system permitted if 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 Na. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED C7 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS L) Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 1 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: "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 applic m st call re Ins C 'on plete drawing on reverse side. Signed Title: ✓V `� Date: R DEPARTMENT USE ONLY �� Application Accepted by Date / Area .Pit or Grout Inspect on by D to 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 If INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. + EH 13-24(REV.i iN 5) .�O t✓t� �7 /'�/► y� G G EH 14-M L� i 1 -fz a- t - l 1