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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 kF MIT EXPIRES 1_YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made.to San Joaquin County4for a permit to construct and/or install the work herein described. This application is rade in complia.nee with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 7 / ��`f Job Address _ /� ®r ®� + _ _ ._ City �" `h' Lot Size/Acreage �fS�-�`� Owner's Name y Address _ Phone ^ t Contractor h � �/ -�� Address `� ��''�� ` License No, y:73996151D Phone 7 per"t7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out ervice well ❑ ! PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 0TH Monitoring Well ❑ DISTANCE TO NEARE : SEPTIC TANK SEWER LINES DISPOSA�F ..-_-' PROP. UNETION AGRICULTURE WELL 0 PITS/SUMPS _ INTENDED USE TYPE OF W ROBLEM AREA CONS N SPECIFICATIONS C] Industrial ❑ Open Bottom ❑ Ma ra. of Well Excavation Dia, of Well Casing 11 Domestic/Private Cl Gravel Pack cy asing Specifications i"1 Public fl Delta Depth of Grou Type of Grout I I Irrigation �.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Don Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Materiel & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.I Installation will serve: Residence— Commercial e Other Number of living units: Number of bedrooms " Character of soil to a depth of 3 feet: _ ^` Water table depth SEPTIC TANK. Q Type/Mfg Capacity r No. Compartments d PKG. TREATMENT PLT. ❑ Method of Disposal r Distance to nearest: Well Foundation Property Line r LEACHING LINE Cl No. & Length of lines .Total length/size FILTER BED n Distance to nearest: Well Foundation t Property Line SEEPAGE PITS 11 Depth Size Number SUMPS' Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS I ❑ 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 m st call for alit qui inspections. Complete drawing on reverse side. Signed 'r/Title: ✓16".? 04yw,�P Date: ¢ ® FOR DEPARTMENT USE ONLY -7 } Application Accepted by0/ Date r' � Ares 2/ 4 Pit or Grout inspection by Date Final Inspection by Date r .Additional Comments: I Applicant - Return all copie-0 to: San Joaquin County Public Health Services, Environmental Health Permit/Services i t _..1601 E:-Hazelton Ave„ P O-Box 2009, Stockton, -CA- 95201- FEE AMOUNT DUE AMOUNT REMITTED CK -NRECEIUED BY 1, DATE PERMIT'NO. INFO CASH . EN3-21 iREV.t i n of - . - - �._