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APPLICATION FOR PERMIT W SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �} ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468--3420 P O BOR 2009, STOCKTON, CA 95201 - P,FMIT EXPIRES_1 YEAR FROM DATE ISSUED :(Complete in Triplicate) Application is hereby made to San Joaquin County for a permit t-'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 _— �(- Pa; lrs In City_ ,�� Lot Size/Acreage Owner's Name/Cdr9/�S6&_ / 49&_� / /_P&res OL) _!2L100 S, Z_YMI/V Phone ,y Conlraclor �Z� Address - H?J� License No. Phone .- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ C PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well CJ a, DISTANCE TO NEAREST: SEPTIC TANK SEWPR'LINES DISPOSAL FLD. PROP. LINE FOUNDATION — AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE €CL" d ROBLEM AREA, CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom 10:1 Nfe�ti Dia. of Well Excavation pia. of Well Casing J1' Cl Domestic/Private ❑ �` i ❑ Tracy Type of Ceasing Specifications 11 Public 1_i Other ❑•D_� th of Grobt Seal!_ ��,.,�. Type of Grout , I Irrigation _.Approx. Depth € I Eastern Surface SeulJ e '� rr"1 Repair Work pone U Type of Pump H.P State Work Done Well Destruction ❑ Well Diameter Material h Depth Depth Fier Material & Depth w, TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITIO I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) , Installation will serve: Residence.X_ _-Commerciel,2Other Number of living units: Number of bedrooms :J 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 f� Distance to nearest: Well 249W _ Foundation -M'---� Property Line + ' LEACHING LINE iA No. & Length of lines Total length/size — FILTER BED ❑ Distance to nearest: Well�0Q Foundation S _ Property Line -_„ SEEPAGE PITS 11 Depth Size _ Number SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 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 cenifies 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 foN c g: "I rte} t he performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa tion laws f Ca fownia." The appli ` t us call or all i d i s ctions. Complete drawing o eve rse sed SignedTitle: ✓ } Date: FOR ENT USE ONLY `` 1 Application Accepted by DateArea Pit or Grout inspection by Data Final Inspection by Date p Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 H. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK 8 CASHj, RECEIVED BY DATE PERMI7'N1O. . EH 13-21 1REV.1!M 5) £H 11-2e l L