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APPLICATION FOR PERMIT 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 EgPIRES I YEAR FROM DATB 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 5Zkopee, City ��J•-+ Lot Size/Acreage Owner's Name • O Address Z;9!4S Phone Contractor AC ddress JLicense No. &LGS7,(b1 Phone TYPE Of WELL/PUMP: NEW WELL ❑ WELL RE -11 DESTRUCTION ❑ Out of Service Well PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER O 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 A-KtA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Mghteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ' Cl Gravel Pack E7 Tracy Type of Casing_ Specifications f"l Public 1:1 Other n Delta /,-'- Depth of Grout Seal ' -Type of Grout I I Irrigation _.Approx. Depth I I East erh Surface Seal Installed by Repair Work Done L1 Type of Pump --n�� H,P. Stats Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth biller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is available-within 200 feet.) Instsflation 481 116-4: Residents_. Commercial_ Other € Number of living units: Number of bedrooms l Character of sol)to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ T i ypa/M1g Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line t•-- LEACHING LINE C} No. 6 Length of lines Total length/size FILTER iBED ❑ Distance to nearest: Welt. Foundation Property Line s SEEPAGE PITS ( I Depth Size Number - SUMPS Ll- Distance to neared: Well Foundatiow` 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 Son 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 shell not employ any parson'n such manner as to become subject'to workman's compensation laws of California."Contractor's hiring or sub-contracting signature cartifies the folio Ir "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 ia." The applica t call for alt req i inspe.c s. Complete drawing on reverse side. _ Signed l Title: Date: ' .r R EPARTME SE ONLY —..Application-Accepted by Date � A►ba � f Pit or Grout Inspection byDate Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 4545 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT�DIfJ�E' AMOUNT REMITTED C K H RECEIVED BY DATE PERMITNO. . EH 13.24 IREV.i/Rel Ek 14-M I\ �