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APPLICATION FOR PERI!I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EMIRES 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 compllance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County PublicHealth Servi�ces.�ca D ,/Job Address lS(a I (O SiA'f F4J City pot� Lot Size/Acreage �C✓E''S Owner's Name - `T M Address 1✓ e L( SPrNlb S_ Phone r741-12+0 Contractor w QtN3ywv �Address License No. Phone STYPE OF WELL/PUMP: NEW WELL ❑ WELL LACEMENT n DESTRUCTION ❑ Out of Service Wel3 PUMP I ALLATION 13YSTEM REPAIR ❑ OTHER 0 Monitoring w ❑ DISTANCE TO NEAREST: SEPTIC TAN SEW LINES DISPOSAL FLD. PROP. LINE FOUNDATION RICULTURE WELL OTHER WELL PITS/SU INTENDED USE TYPE OF WELL P LEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Man a Dia. of Well Excavation Well Casing Ca Domestic/Private ❑ Gravel Pac ❑ Tracy Type of Casing_ Specifics' ns l'1 Public - EI Other fl Delta epth of Grout Seal Type of Gro I I Irrigation _. pprox. Depth l I Eastern Surface Seal Installed by. Repair Work Done 0 Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth a Filler Material i Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I ) REPAIR/ADDITION DESTRUCTION I I Wo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence V/ available _ Other Number of living units: __J,.._ Number of btdrooms 3 Character of still to a depth of 3 feet: 5 Water table depth SEPTIC TANK. ❑ Type/Mfg -V Capacity No. Compartments PKG. TREATMENT PLT.❑ ! Method of Disposal Distance to nearest: Well Foundation Property Line t11 � LEACHING LINE No. 6 Length of lines _ _ i Total length/size FILTER BED 0 Distance to nearest. WelltZ�r Foundation 1 r Property Line 4 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: "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 lava of California." The applicant must call for all {required inspections. Complete drawing on reverse side. Signed X_ �11(,� --- Title: IYWIr Date: I� FOR DEPARTMENT USE ONLY .� t Application Accepted by clw.la. Date Z Area //,,ll// Pit or(trout Inspection by Date Final Inspection Date��, Additional Comments: // %%%%%""""" Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 R San Joaquin, P O Box 2005, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. r EN 13,24(REV.1/M til 4/ 6) � j ) �7y EN 14.71 ' r 3 :�K !t �`/ ��7