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I APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION i 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P O BOR 2009, STOCKTON, CA 98201 pFaMIX EXPIRES 1 YEAR FROM DAT ED (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. �j Job Address S E �Q d v` ` �� - _ city 4� Lot Size/Acreage Owner's Name Address S Phone 2� Contractor 1 rki Address POA6License NIC2 3 �Phone ld TYPE OF WELL/PUMP: NSW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION t of Service Well ❑ ' PUMP INSTALLATION O SYSTEM REPAIR ❑ i , OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [.l Domestic/Private ❑ Grave) Pack ElTracy Type of Casing Specifications C1 Public 1-3 Other 11 Delta Depth of Grout Seal Type of Grout - I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State rk e Well Destruction Well Diameter -- - Sealing Material & Depth O n -a J> Depth Filler Material & Depth 7 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other # CO 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 PET. ❑ Method of Disposal Distance to nearest: Well foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED L7 Distance to nearest: Welt Foundation Property Line SEEPAGE PITS 11 , Depth Size Number SUMPS LI 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 Horne 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 applicant mmu[stt scall for all required i speytions. Complete drawing on reverse side. Signed __ 2"`-�� elLLLlA4t2!�.. Title: See o-e `� Date: , om== Y Q Application Accepted by Date Area y Pit or Grout Inspection by Final Inspection byAdditional Comments: Applicant - Return all copies to: San Joaq,Date County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED " RECEIVED BY OATE PERMIT'N0, INFO CASH -ry r� l rJ . EHU-24MEV.rin5l 3 �s{)U �� Y�� V^rLfJI EH 14.26