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r"*% APPLICATION to-1 LLS 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 EXPIRES I 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 1862 and the Rules and Regulations of San Joaquin County Public Health Servi1_0 ^Job Address 0_L yt„ C( vie, _ Ci y Lot Size/Acreage A Owner's Name .L�G! /� f TO Address '�+ y 0ZOEc AI 0,1! Phone r Contractor Cl ddress License too. Phone l 46 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well 0 PUMP INS LLATION ❑ SYSTEM REPAIR Cl OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE WELL,,— OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL XManleia. TRUCTlON SPECIFICATIONS ,fit C1 Industrial D Open Bottom . of Well Excavation Dia. of Well CasingCl Domestic/Private C] Gravel Pack e of Casing_ Specifications I'I Public Ci Other pth of Grout Seal Type of Grout lfrigation �.Apprax. Depth a 5aa4 knstalled byRepair Work Done 0 Type of PumpState Work Done Well Destruction 0 Well Diameter Sealing Material Depth Depth Filler Material & Dep TYPE OF SEPTIC WORK: NEW INSTALLATION 13 REPAIWADDITION I I DESTRUCTION KNo septic system permitted if public sewer is available within 200 feet,) Installation will serve: Residence_.__ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ? A Water table depth SEPTIC TANK ❑ Type/Mfg ° i No. Compartments PKG. TREATMENT PLT, Cl Method of Disposal Distance to nears PerTAemay#AFUaX9h`6vd� Property Line LEACHING LINE Cl No. & Len a r1 Length of lines ��f '� l length/size FILTER BED Cl Distance to nearek j:y ilVfi� 1� _ Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation _ 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, 1 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 Calif rnia." The applicant m st cal for 11 required inspections. Complete drawing on reverse side. �( Signed x Title: f� c.,.._ Date: DR DEPARTMENT USE ONLY Application Accepted by Date__, `l`9 Area Pit or Grout Inspection bey Date Final Inspection by Hata Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO, • EM13-24 IAEV,I/a 5) S I�^7 r 4 O ' EH t4.n —