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I APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 I P O BOX 2009, STOCKTON, CA 95201 PERMIT E%PIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application in hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compliance with San Joaquin county Ordinance No. 549 and 1862 and the Rules and Regulations of San i Joaquin County Public Health Services. J� �✓ n Job Address __!fJ r ��d (! P. City�r� Lot Size/Acreage Owner's NSIS' -5,yye cl /4 [/ ame � Address Phone Contractor AN t? `'If ;F Address JRi,it k V4UT 'A/p License No. y J _Phone TYPE_'OF WELL/PUMP: i; _NEW WELL ❑ WELL RE LACEMENT n DESTRUCTION ❑ Out of Service Well ❑ YPU P-IN5rtA4LATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring 1fe11 n DISTANCE TO NEAREST: SEPTIC TANK "`° SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS tNTENDED,US__£ TYPE OF WELL PR09LEM AREA CONSTRUCTION SPECIFICATIONS I] Industrial �.--"O-Open4ottom ❑ Manto"ca'J Dia. of Well ExcavationDia. of Well Casing f Domestic/Private I-] GA Pack`s ,� El Tracy . y 4` Type of Casing_. _ Specifications f'I Public fl Other r] Delta :,Depth of Grout Seal Type of Grout I i Irrigation �Approx. Depth ;,: 1-Eastern Surface Seal installed by F Repair Work Done U �Type:loll Pumpx. H.P. `��- State Work Done ww� Well, Destruction 13Well Dismetai Z14- Sealing lfaterial• i Depth oepth `'~ .biller Material i Depth * X11- TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic-system permitted if.public sower is .^:.M, _^,'available,within 200 feet.) ' Installation will servo: Residence-L- Commercial.= r� Number of living units: � Number of bedroomCs -� i Character of 800 to a depth of'3 feet: �V Water table depth f� SEPTIC TANK Type/Mfg Capacity-L2-0—'0 No. Compartments - PKG. TREATMENT PLT. ❑ ll, Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE , Noh m Length of lines $O r Total length/size AD FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS 11 Depth Size Number t SUMPS LI Distance to nearest: Well,. Foundation Property Line v DISPOSAL PONDS ❑ iN 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 OF subcontracting signature certifies the following: "l certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." I"�• I The applicant must all for all required inspections. Complete drawing on reverse side. , Signed Title: Date: 'Y 2 !� FO EPART NT USE ONLY Application Accepted byDate A— . a _ 1 Pit or Grout Inspection by `` Date Final Inspection b",. ^Dat./ 1 Additional Comments: Applicant - Return allit copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2008, Stkn, CA 95201. FEE AMOUNT OlJE AMOUNT REMITTED INFO RECEIVED BY DATE PERMIT'f40. IZ . ENI 7.2z IREV,r i H 61 �i• a EH tt.ta / , 4 /�' a a d?� !iii' ,V,6