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s APPLICATION FOR PERMIT �d SAN 'JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONI[ENTAL HEALTH DIVISION L ` 445 N SAN JOAQUIN, PHONE (209)488-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXP I RES I 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 snide in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. I ?i )(Job Address I � --q d7h _ City Lot Size/Acreages XOwner's Name Address Pae �Cgntracla - - Address x License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION 0 Out of Service hell -0- PUMP INSTALLATION OSYSTEM RE R 0 OTHER ❑ Monitoring Well C] DISTANCE TO NEAREST: SEPTIC TANK EWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION A (CULT WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WE PROBLEM CONSTRUCTION SPECIFICATIONS C7 Industrial O Open So m O eco D+ . f Mall Excavation Dia. of Well Casing n Oomostic/Private ❑ Gravel ack Tracy Type of Casing Specifications I'I Public 1-1 Ot (l Dehs Depth of Grout Seal Type of Grout I I Irrigation A it. Oapth i I Eastern i Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION INo septic system permitted if public sewer is vailabls within 200 feet.) Installation will nerve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of sola to a depth of 3 feet: Water table depth SEPTIC TANK. L0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No. IN Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line /�► •L SEEPAGE PETS 11 Depth Size f Number SUMPS LI Distance to nearest: Well f Foundation Property Lire 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 Hones owner or licensed agent's signature certifies the following: "I cenify 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."Contractors hiring or sub-contracting signature certifies the following:"I certify that in the psrfomnance of the work for which this permit is issued, I shall employ persona subject to workman's compensa- tion laws of California." The applican must cell f r 2 Complete sons. Complete drawing onnreverse _side. AlSigned>< / ?� %Title: _ �dsm _. Date: J. ryf/fL.t� FOR,DEPARTMENT USE ONLY Application Accepted by 'yL i+ , . ,,. .. Dots / Area Pit or Grout Inspection by Date s Final Inspection by Date Additional Comments: I r,, Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 55201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK A RECEIVED BY DATE PERMIT'NO. • EH 13-24[ItEV.a/K a ( P a , EH 14-M f. r �E