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APPLICATION FOR PERMIT SAN( JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOR 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application in hereby mede,to San Joaquin County for a permit to construct and/or install the vork herein described, This application is made 1n compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address � � �1r 2 ,,4 . City.-�Z-../--.cG_ Lot Size/Acreage Owner's Name 4a,6j / ifAFi7x�_ Address �I Phone Contractor F"YP E ik-'.il Address� N. .get/ALL> /f!/E License No. 7.�S-Z„7 _phone S= 9 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION GRICULTURE L OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLE RE CONSTRUCTION SPECIFICATIONS ❑ Industrial ETD pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Trac Type of Casing Specifications 1'I Public Cl Other fl to Depth of Grout Seal Type of Grout In igation _ Approx. Depth Eastern urface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Me rlal 6 Depth Depth Filler Material i Depth (f� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I (NO septic system permitted it public sewer is -2 (� Installation will serve: Residence_ available within 200 feet.)Commercial _ Other /1 ,N / Number of living units: / Number of bedrooms _L�_ r QAC E 7-4 N/� ©/V L,,�,' - Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg P9r- Capacity l Z�dPJ No. Compartments Z PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well �. _ Foundation S Property Line /e ' LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED CI Distance to nearest: I Foundation Property Line SEEPAGE PITS 11 Depth _ Sixe Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl I hereby comity 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 workmen's compensation laws of California." Contractor's hiring or subcontracting 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 cal or all required inspections. Complete drawing on reverse side. Signed K ev Title: _C� Z' Date: FOR DEPARTMENT USE ONLY Application Accepted by Date 7 [� Area Pit or Grout Inspection by Date Final Inspection by "i-v � Date �d Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health ��J• �- Services, Environmental Health Permit/Services ��,1\ 1601 E. Hazelton Ave., P 0 Box 2009. Stockton, CA 95201 FEE AMOUNT DtlE AMOUNT REMITTED CK RECEIVED aV DATE PERMIT'N0. INFO CASH . EN 1324 IaEV.i/nsl v\ Il y. f �. __Z.� I cit/_ /�24Z EH 1E.20 X`