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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 O BOX 2009, STOCKTON, CA 95201 PERM IT EXPIRES 1 YEAR FROM DATE Ii5SUED (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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San �/ Joaquin County Public Health Services. /�_ R Job Address 2 � `�r� `�� 7 //1— C�y Lot Size/Acreage ! 7 xOwner's Name �Ul r Address _`��_ - -� Phone Contractor /LJ Address License No. Phone �-- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitor ng Well n DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. P. LINE FOUNDATION AGRICULTURE WELL LL PITS/SUMPS INTENDED USE OF WELL PROBLEM AREA C TION SPECIFICATIONS Industrial CD Open Bottom n Dia. of Well Excavation Dia. of Well Casing f Cl Domestic/Private ❑ Gravel Pack Tracy a of Casing Specifications I'l Public (a t-1 Delta Depth o eal Type of Grout I i Irrigation .Approx. Depth l 1 Eastern Surface Seal Installed f_ Repair one L] Type of Pump H.P. State Wor Destruction ❑ Well Diameter Sealing Material & Depth . 1 Depth Filler Material & Depth [l�J TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I (No septic system permitted if public sewer is available within 200 feet.] Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet: Water table depth U� SEPTIC TANK ❑ Type/Mfg `:Capacity No. Compartments l PKG, TREATMENT PLT. ❑ Method of Disposal f Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation 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 County Home owner or licensed agent's signature certifies the following: 1 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 1 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 callrM. Wrl Ins c 'on plate drawing on reverse side. �( Signed Title: ✓� Date: R (DEPARTMENT USE ONLY10 Application Accepted by Date ° / Area Pit or Grout Inspection by D to Final Inspection by ` � /V t - Date Additional Comments: -- Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services eft 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 ��]l FEE AMOUNT UE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO f/j� CASH /�/� y��t / I EH 13-24(REV.1/x Sl oO OCJ �U l �/t� �`'� f 1-ou l j EH 1426