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f APPLICATION FOR PERIdTT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � � ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 l 'PERMIT EXPIRES 1 FROM DATE ISSUED No (Complete in Triplicate) 1,J4 Application is hereby made'.to San Joaquin County for a.permit to construct and/or install the work h' e'reinbed., This application is made itt ccwlianceivith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. _KJob Address �� }}l l_ S d[r l Aye' City Sfoe, 011 L t Size/Acreage 1� Owners Name _ Kin Q na �t+l� � Address 2"i� ► +t ht Vel Phone r` 33 57 XIC-Ontractor A" Address — L, License No. Phone TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT [-1 DESTRUCTION C1 Out of Service Well ❑ PUMP.INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TAN A qrwrp LINES T DISPOSAL FLO. PROP. LINE F ATION AGRICULTUA OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM CONSTRUCTION SPECIFICATIO x ❑ Industrial ❑ Open Bottom nteca Die: of Well Excavation Dia. of Well Casing CI Domestic/Priv e ❑ Gravel Pack` ❑ Tracy Type of Casing_ Specifications I'I Public !-1 f1 Delta Depth of Grout Seal Type of Grout �\ I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done LJ Type of Pump , H.A. State Work Done w Well Destruction ❑ Weil Diameter Sealing Material i Depth 1 r . FilleMateria1 Depth Depth _ - TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION lNo septic system permitted if public sewer is ailable within 200 feet.) installation will serve; Residence Commercial— Other r l Number of living units: Number of bedrooms (� i Character of soil to a depth of 3 feet: Water table depth (` SEPTIC TANK. ; ❑ Type/Mfg ) Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Len th of lines g Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS —11 Depth ) Size I Number SUMPS LI Distance to nearest: Well Foundation Property Lina DISPOSAL PONDS ❑ I I hereby certify that I have prepared this application and that the work will be done inaccordancewith San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature dertifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not t employ any person in such manner as to beoorna subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the fotlowing:"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." l I The appliean t all for ell rsquir pspacoons. Complete drawing on reverse side. Signed Title: 0 Yin 1W Date: _ R D RTMENT_USE ONLY A rea Application Accepted by _ �- "� ata Pit of Grout Inspection by 1 Date Final Inspection by Date z �� Additional Comments: 1. r Applicant - Return all copies toe San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2008, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATE PERMIT ND. . EH 1721 fREv.tietsi Mo CIV, EH 11.211 /' V'