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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 EXPIRES 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 compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. y Job Address !_ -/_ _�1�.--Se LC _C_ _ City S Lot Size/Acreage �o� , !' 165' Owner's Name kliri k, t Address /2&6 ac9. se ty-/err Phone ~ Address 12 496 r. 4ZCity CGle TYPE qF WELL/PUMP: NEW WELL 11 WELL REPLACEMENT ❑ DESTRUCTION C1 Out of Service Well ❑ PUMP INSTALLATION C] SYSTEM REPAIR C7 OTHER f] Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL.,E PROP. LINE AGRICULTURE WELL ER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLSTRUCTION SPECIFICATIONS C_� Industrial O Open Bottom nteca Dia. o avation Dia. of Well Casing Ci Domestic/Private C7 Grav L1 Tracy Type of Casing Specifications I'I Public = Other n Delta Depth of Grout Seal Type of Grout I I IrdUati _..Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L] Type of Pump H.P. State Work Done Well Destruction 0 Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION fflEPAIR/ADDITION I i DESTRUCTION I i Ilio septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence Commerciaf_ Other Number of living units: / Number of bedrooms 3 i Character of soil to a depth of 3 feet: .rr - a r D Water table depth SEPTIC TANK e Type/Mfg �apacity Bt.0 No. Compartments PKG. TREATMENT PLT. ❑ , Method of Disposal Distance to nearest: Well �QQ_ Foundation [ Z.T Property Line 19 LEACHING LINE ❑ No. & Length of lines C il Total length/size I Z.o FILTER BED ❑ Distance to nearest: Well 41,90 Foundation - 3 C Property Line --- t SEEPAGE PITS 11 Depth SizeLl __ Number SUMPS Cl Distance to nearest: Well ff�0 , Foundation /00 Property Line-_ /oo DISPOSAL PONDS ❑ 1 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." The applican st call fo II re in ons. Complete drawing on reverse side.'IS / igned Title: 56V ��/✓� 1. �✓ Date: FOR DEPARTMENT USE ONLY Application Accepted by t"` ` t Date A a Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEEINFO A OUNT DUE LINT REMITTED CLASH RECEIVED BY DATE PERMIT'N0. EN 1 -241REY.ein51 .f► 1� r� j �o (, ! �+J�yQ EH 1426 '` f I ( ! IVl