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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ] j ENVIRONMENTAL HEALTH DIVISION L 1601E HAZELTON_AVE. , PHONE (209)468-3420 �r P 0 BOX 2009, STOCKTON, CA 95201 ��" '+S PERMIT EXPIRES 1 YEAR FROM 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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address rS Id City .1c(MK) Lot Size/Acreage Owner's Name A/`T/1/C y 4, 3QAI-51 QAddress � 5csr44 C Phone — Contractor L Address 4 License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well L7 DISTANCE TO REST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE NDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF W ROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial O Open Bottom ❑ Man Dia. of Cl Domestic/Private O Gravel Pack O Tra y asing Specifications FI Public Cl Other Delta Depth of Grout Type of Grout I I Irrigation pprox. Depth ( I Eastern Surface Seal Installed by Repair Done U Type of Pump H.P. State Work Done_ Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth + TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION IKJNo 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 No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 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: "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 subcontracting 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 applicant must call for all require ins ctiona. Complete drawing go reverse side. Signed Title Date: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date ` L Area_ p Pit or Grout Inspection by Date Final Inspection by �� h Date o 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 INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. . EM 13.21 IREV,t i n 5)50 L41) _ EH M-69M-2a l l!!