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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468--3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT MIRES 1_YEAR FROM DATE- ISSUED (Complete in Triplicate) i 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 1$62 and the Rules and Regulations of San Joaquin County Public Health Services.a Job Address O gI,7 S S��'y� 12!^Z llRCity 6e�/,C�rTeA) Lot Size/Acreage • e. Owner's Name Address " Z;2-5/ !�l �� oaD, T Snt�/ �1Phone S,x 30d Contractor_E_Z_- Z2 25. W.00D Address mit/, 4?fk License No. S 7'G Phone r-3ct71 TYPE Of WELL/PUMP: NEW WELL © WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION E) SYSTEM REPAIR ❑ OTHER D 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 f?ROB M AREA CONSTRUCT N SPECIFICATIONS f} Industrial ❑ Open Bottom C] Mantec Dia. all Excavation Dia. of Well Casing ❑ Domestic/Private C4 Gravel Pack ' El Tracy ype of Casing Specifications I'I Public CI Other fl Detta epth of Grout Seal Type-of Grout I I irrigation —.Approx. Depth f ICE to Su a Seal Installed by I Repair Work Done U Type of Pump H.P. State Work Done _ 'Well Ustruction.. .❑ Well Diameter Sealing Material epth Depth Filler Material & Depth ' TYPE OF SEPTIC WORK: NEW INSTALLATION JY ' REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is available within 200'leet.i Installation will serve: Residencer! Commercial Other Number of living units: Number of bedrooms Character of soil to a depth n L h of 3 feet: A Water table depth SEPTIC TANK. t� Type/Mfg e ~ P L ' Capacity f d No. Compartments y PKG. TREATMENT PLT.0 �*. t Method of Disposal Distance to nearest: Well _,,, !_ Foundation to! Property Line 1zs� LEACHING LINE Lrf No. & Length ai lines -2- gs Total length/size Z 70 FILTER BED ❑ Distance to nearest: Well a�� r Foundation 6-O ,r '.'Properly Line SEEPAGE PITS lW Depth:- -. -Size_ 3G Number.-- SUMPS .Ll Distance to nearest: ❑-Wali; 1:90 r Foundation /Dy Property Line 9D DISPOSAL PONDS D 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." N -. The applicant must call for all required inspections.--.Complete drawing on reverse side. Signed XTitle: — Date:Sa - R DEPARTMENT USE ONLY 7 Application Accepted by Date Area �! i Pit or Grout Inspection by Date Final Inspection by Date -S Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services ` 3601 E. Hazelton Ave., P 0 Box 2009, 'Stockton, CA 95201FEE G9]�' INFO AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY DATE PERMIT'NO. i EH 13-241REV.1/"5! EH 34 2s 6