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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 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) �0�_ 24,o- oL 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 H alth Services. ,�-3`sa Job Address A-0 tip/N-- City �� Lot Size/Acreage Owner's Name ti/doH7E 12/2-0/2410 77—S ►UGAddress 4303f W, q _.0 'd`YYf3 Phone 957-/ 3 Contractor FLoyp --• _lrgoo-h Address ,. 7 _7JP , vPhone 54i`'3 7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C] OTHER.p Monitoring Well L7 DISTANC REST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE DATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF)74ROSLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom O Man Dia. of Well Excavation Dia. of Well Casing E: Domestic/Private ❑ Gravel Pack E3 Tracy Casing Specifications I'I Public 1-1 Other F1 Delta Depth of Grou Type of Grout i I Irrigation _..Approx, Depth I I Eastern Surface Seal Installed by Repair Work Done 13 Type of Pump H.P. State Work O] Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION JJI(T REPAIRlADDITION I I DESTRUCTION i I lNo septic system permitted if public se er is / available within 200 feet.) Installation will serve: Residence�/. Commercial— Other Number of living units: ---L Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg cc -- P4L- Ca acit (0290 p y�� No. Compartments 1- PKG. TREATMENT PLT. ❑ _ Method of Disposal Distance to nearest: Well Foundation s Property Line Pa LEACHING LINE L No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well.,JSb ' Foundation -529' Property Line SEEPAGE PITS is Depth �� Size Ir' Number SUMPS U Distance to nearest: Well f 7 5 Foundation go 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 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 sub-contracting 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 applicant must call for all required inspections. Complete drawing onreverse �side. Signed X Title: dew-r L Date: &5 T�'a F0 F R DEPARTMENT USE ONLY Application Accepted by Date Area 2 Pit or Grout Inspection by Date Final Inspection by Date-2 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hat;elton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATE PERMITNo: . EH 13-24 fREV.r/H 5) •�� 1(0 EH'.4-25f a , C90 �u-C / �