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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELT'ON AVE. , PHONE (209)468-3420 s ; ,1 P O BOX 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 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 7-2-C/ /�L.'.c7,Bfl�b A //G. City S-7 exf Lot Size/Acreage /OOXµ2y1 Owner's Name DA✓/r0 Rci/iADOlVdA Address S14-r"-- Phone9,31-17 P Contractor FLe YD 6'. fit/ Address 7n/. AD a er "t 40:,,5_License No. 'S'�7�176 Phone -$ .971 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER C1 Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK EWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION A R]CULTURE W OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL Af STRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom . of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack e of Casing Specifications I'1 Public 1-1 Other th of Grout Seal Type of Grout I I Irrigation _Approx. Depth a Seal Installed by Repair Work Done ❑ Type of PumpState Work Done _ Well Destruction ❑ Well Diameter Sealing Materi 6 Depth Depth Filler Material 8 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 1 I DESTRUCTIOpermitted If public sewer is available within 200 teet.l Installation will serve: Residence Commercial _ Other LOT OF 6X/ST/ti 6- /2 CCel,01] Number of living units: Number of bedrooms 2- Pie/e e 7Z- /9 7.Z N Character of soil to a depth of 3 feet: eLAY a epth SEPTIC TANK 11r_Type/Mfg CG - !mow L Capacity 9060 No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well 7Foundation I,Q Property Line 40" LEACHING LINE No. & Length of lines 3 -/�r7 r Total length/size /60 FILTER BED ❑ Distance to nearest: Well lojr Foundation IeV I Property Line 4V .5- SEEPAGE PITS III Depth ,;kS Size 4-1-11 Number 3 SUMPS LI Distance to nearest: Well _/Z Foundation ZOO 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 agents 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." Contrectoi 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 must call for all grequired 'inspections. Complete drawing on reverse side. Signed X r—�`�-.cam Gib-a-zAC/ Title: l� Date: 7-I9-gra r� _^ i EPARTMENT USE ONLY A � ' pplication Accepted by `A�•kCL,v i.._- wAi. _ _ Date Area Pit or Grout Inspection by Date Final Inspection by 7 '" -��/Y Data Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Razelton Ave., P 2009, Stockton, CA 95201FEE wti INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT NO. . EH 13-24[REV . _ �- �r[� EH 4 1 2N l l.I