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*) APPLICATION FOR PERMIT '' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201, PERMIT EXPIRES 1 YEAR FROM DATE ISSU (Complete in Triplicate) - t 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 1662 and the Rules and Regulations of San i Joaquin Count Public Health Services. Y XJob Address m- City Lot Size/Acreage �Z 4(t?r1` XOwner's Name � �n� -_ Address —7-rr7 SQ�.� Phone �-3 f NConlraclDr Address 7 e License No. Phone TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACJPMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTA ION SYSYROCREPAIR ❑ OTHER ❑ Monitoring Well O DISTANCE TO NEAREST: SEPTIC TK SEWER LIN DISPOSAL FLD. PROP. LINE ,04 FOUNP4TION XGRI URE WELL OTHER WELL PITS/SUMPS INTENDED USE T E OF WELL PROS EA CONSTRUCTION SPfCIfICATIONS ❑ Industrial Open Bottom anteca Dia. of Well Excavation Dia. of Weil Casing C7 Domestic/Private Gravai Pack C] Tracy Ty sing_ Specifications I'I Public 1-1 Other , Cl Delta Depth of Grout Seat Type of Grout I I Initiation / prox. Depth I I Eastern Surface Seal Installed by / Repair Work Done ps of Pump H.P. State Work Done I k Well Destruction ❑ Well Diameter Sealing Material i Depth I j Depth filler Material i Depth O TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION l I (No septic system permitted if pttblic sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other _ _-Number-.of_Wng-units:--Z.---Number-0f-bedrooms CharWw of w#to a depth 1 3 feet: Water table depth SEPTIC TANK. L� Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well /4111/'_tFoundation Property Line k LEACHING LINE ;'I' No. 6 Length of lines LUQ Total tength/size 6 f' f / FILTER BED ❑ Distance to dearest: Wetl�F�Foundation 0 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 Horne gen s owner or licensed sprit's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ arty..person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the fo#owing: "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 Californla." The applicant must call for required inspections. Complete drawing on reverse side, y �t Sig Title: Date: v \ OR DEPARTMENT USE ONLY Application Accepted by Date r�d�L✓ �-� Area �^ Pit or Grout Inspection by 1 Date Final inspection by Date Additions! Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental-Health Permit/Services 445 N San Joaquin Box 2009, Stkn, CA,95201 FEE AMOUNT DUE AMOUNT REMITTED CK H R EIVED BY O TE PERMIT NO. / 71 EH 13-24 Ir1EV.f i n S! S Q I EH 14-26 /// {{{ ✓✓✓