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r APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOR 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 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 862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address City of Size/Acreage2" . Owner's Name W^r' Address S Phone a /r� Contractor _ SS t License No.Y10_iPhone TYPE OF WELL/PUMP: if NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ YSTEM R IR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINEDISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTUR W /4 OTHER,WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEJSealing TRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Mantf Well Excavation Dia. of Well Casing C_l Domestic/Private ❑'Gravel Pack ❑ Tracof Casing Specifications f'l Public Cl Other F1 Delta of Grout Seal Type of Grout I I Irrigation �.Approx. Depth I I Eastee Seal Installed by Repair Work Done U Type of Pump State Work Done_ Well Destruction ❑ Well Diameter ial & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DE TRU TIO I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence &/Commercial ther Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ��-----�� Water table depth SEPTIC TANK ❑ Type/Mfg *L C Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1 Method of Dispos Distance to nearest: Well so Foundation 40!�C' Property Line LEACHING LINE D No. & Length of lines T tal length/size FILTER BED 0 Distance to nearest: Well oundation-ZLV Property Line SEEPAGE PITS 11 Depth Size Nu ber ot SUMPS LI Distance to nearest: Well f Qty Foundation Property Line r 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 ust call for squired 'nspections. Complete drawing on reverse side. Signed X Title: Date:IF DEPARTMENT DEPARTMENT USE ONLY Application Accepted by A Date -TO Area Pit or Grout Inspection by Date Final Inspection by Date 2� Additional Comments: Applicant - Return all copies to: San JoaquinCountyPublic Health Services, Environmental Health Permit/Services Vrv , 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. + EH 13.24(REV.t i R 5) + D.(] S J' fJ•� ® 1(�o �-14a EH A2s