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M 0 II APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES IEENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 ii P O BOR 2009, STOCKTON, CA 95201 �I pERMIT EXPIRES 1 YEAR FROM DATE (Complete in Triplicate) ii Application is hereby made,to Saar Joaquin County for a permit to construct and/or install the work herein described. This application is made in conpliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address J ' oo II`� C 2 " City. Lot Size Acr ge Owner's Nameyl Address Phone 25 Contractor LC Address License No. Phone TYPE OF WELL/PUMP: II^ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑- �. PUMP INSTALLATION ❑ SYSTEM_REP-AIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES QISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL - :PITS/SUMPS r INTENDED USE TYPE OF WELL_1 PROBLEM AREA CONSTRUCTION SPECIFICATIONS' ❑ Industrial 11 Open Bottom �❑-Mantecal Dia. of Well Excavation/ Dia. of Well Casing CI Domestic/Private ❑ Gravel Pack LJ Tracy ' Type off�C�asing' }' Specifications i I'1 Public !.l Other F1 Delia Depth oaf Grout Sea! ,Type of Grout I I irrigation _..Appfox. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of-Pump A, H P � --- State Work Done_ Wel! Destruction ❑ Well giameter Sealing Material &,Depth Depthl Filler'Naterial & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I. REPAIR IADDITIONK DESTRUCTION<f INo septic system permitted if public sewer is j �i /- available within 200 feet.) ` installation will serve: Residence✓ Commercial--,-Other � Number of living units: N f 'I umber of bedrooms �, x Character of soil to a depth of 3 feet: 01 L_A y Water table depth SEPTIC TANK:--- p--Type/Mfg Capacity � �Ir� No. Compartments - PKG. TREATMENT PLT. 0 �' ' �• ,, Method of Disposal Distance to nearest: Well ��G foundation Ptciparty Line � •fs/ 1 ' r Total len th/sire / 7 c7 r c LEACHING LINE No, & Length of lines Z � g � �� 9 FILTER BED ❑ ' Distarice'to nearest: Well Foundation �2.tf r Property Line ^ ti, lig � SEEPAGE PITS 14 Depth �� Size " Numbers 2� SUMPS L3 Distance to nearest: Well 100t Foundation Property Line (& 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'ssignature 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 California." r The applicant must call ora I'required nspections. Complete drawing on//rl!everse side, j Signed X r - ':' TideC�• -- _-- Date: '/ �f I OR PARTMENT USE ONLY Application+Accepted by 4AN, Date. �� - Area Pit or Grout Inspection by II Date Final Inspection by 11JA I. Date D Additional Comments: v l w 1 ii Applicant - Return all copies to: San Joaquin County Public Health 11 Services, Environmental Health Permit/Services k ,r 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY PATE PERMIT'N0. � INFO Ij> Q� Q EH k324{REV.r/n51 �9(� /f # !//� I 10. i' EH:4.25 `