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_ APPLICATION FOR PERMIT - SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1 ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$--3420 P 0 BOX 2009, STOCKTON, CA 95203 PERMIT EXPIRES 3 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 ___�__/ V � 9tIF G!fif /Gr✓Y City Lot Size/Acreage Owner's Name -_ _- Address42 c � /(/ - Cantractar4 License No. Pho TYPE OF WELL/PUMP: N ELL ❑ WELL REPLACEMENT-C:i DESTRUCTION ❑ Out of Service hell C.l PUMP INSTALLATIO SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C ., DISTANCE TO NEAREST: SEPTIC TANK S LINES "° .DISPOSAL F _ ROP. LINE FOUNDATION-:--"-:-:' AGR1CUl WELL -~ WELL - PITS/SUMPS- INTENOE_D USE_TY_PE OF WELL P_RO_ BLEM AREA _ ii ON SPECIFICATIONS n Industrial ❑ Open Bottom ca Dia. of Well Ex ca Dia.o}WeII'Casing ; Ca Domestic/Private. Ci Gravel ❑ Tracy Type of Casing Specifications f' F1 Public the( 11 Delta Depth of Grout SealType of Grout a I 1 Irrigation T Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done Ll Type of Pumrp H.P. State Work Done f, Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material 6 Depth # e J TYPE OF SEPTIC WORK; NEW INSTALLATION f I REPAIR/ADDITION I 1 DESTRUCTION 1 tNo septic system permitted if public sewer is available within 200 feet.) s n Installation will serve: Residence Commercial_ Other 1) �JJJ 1 i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:I Water table depth t SEPTIC TANK. - 0 Type/Mfg. Capacity No. Compartments 1 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size ,y FILTER BED ❑ Distance to nearest: Well Foundation Property Line ? SEEPAGE PITS 11 Depth Size T Number SUMPS LI Distance to nearest: s Well -Foundatioh DISPOSAL PONDS ❑ , I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and i rules and regulations of the San Joaquin County i 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 wworkman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following; "'!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 mu all for al require '�spections. Complete drawing on reverse side. r 1 q Signed X Title: 2� Date: _ �l` ! FOR DEPARTMENT USE ONLY Application Accepted by Date L Area Pit or Grout Inspection by Date Final Inspection by Dat - '9� j Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, .Environmental Health Permit/Services f 1601 E. Hazelton Ave., P 0 Box 2009,. Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED SASH RECEIVED BY DATE PERMIT N0. + EH 14-21(REV.1/015) EH 51-26 111 3