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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I ENVIRONMENTAL HEALTH DIVISION Il 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 No P.ESMIT EXPIRES 1 YEAR FROM DATE ISSUED �. (Complete in Triplicate) a 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,Ser_vices. Job Address 10-7 k1h - City Lot Size/Acreage }wner's Name Kl f11/. � '* lel' U , 1`��tCddr�ess rr07 0� i alkR.P! �f'L _ Phone 1` Contractor ��.l�fLtC�t Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ n WELL REPLACEME ❑ DESTRUCTION ❑ Out of Service Well Cl PUMP INSTALLATION ❑ SYSTEM RE lR ❑ OTHER ❑ Monitoring well [7 DISTANCE TO NEAREST: SEPTIC TANk. SEWER LI S DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTU WE OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CON RUCTION SPECIFICATIONS ❑ Industrial 111 Open Bottom ❑ /aDt,. of ell Excavation Dia. of Well Casing 1.) Domestic/Private ❑ Gravel Pack ❑ e of Ca 'ngSpecifications ['I Public Cl Other t11 th of Gro Seal Type of Grout I I Irrigation _..Approx. Depth [ I face Seai In kled by Re air Work Done U T pp ype of Pum State Work DoneWell Destruction O Well Diameter erial & DepthDepth rial & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION (No septic system permitted if public sewer is vailable within 200 feet,) Installation will serve. Residence_J Commercial— Other Number of livingunits: 'Number r of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line 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 I 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 cartify 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 applic m st call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: 3--23=1_T OR DEPARTMENT USE ONLY Application Accepted by Date Area i Pit or grout inspection by Date Final Inspection by Date Additional Comments: j Applicant – Return all copies to: San Joaquin County Public Health k Services, Environmental Health Permit/Services € 1601 E. Hazelton Ave.. P 0 Box 2009, Stockton, CA 95201 IF 0 MOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. j s EH 13-24(REV.tin5i /�' �/y EN i4-25