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APPLICATION FOR PERMIT Y SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P 0 BOR 2009, STOCKTON, CA 95201 RTMIT 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 vith San Joaquin County Ordinance No. 549 an 1862 and the Rules and Regulations of San Joaquin County Public Health Services { Job Address City J Lot Size/Acreage il. r-.• Owner's Name Address Phone-&.— Contractor :fjo Address 7Q^ License No. Phone TYPE OF WELL/PUMP: V NEW WELL ❑ VICULTURE L REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK S DISPOSAL FLO. PROP. LINE FOUNDATION WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLE REA CONSTRUCTION SPECIFICATIONS C1 Industrial D Open Bottom /Eastern eca Dia. of Well Excavation Dia. of Well Casing Cl Domestic!Private ❑ Gravel Pack = .Type of Casing. Specifications I') Public I-1 Other Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I Surface Seat Installed by Repair Work Done U Type of Pumps WP State Work Done _ Well Destruction ❑ Well Diameter Se ing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ( I REPAIR/ADDITION I I ESTRUCTiON ) INo® septic system permitted if public sewer is aa'able within 200 feet.) Installation will serve: Residence^ Commercial— Other /f Number of living units: Number of bedrooms /I n !-� s� Character of soil to a depth of 3 feet: ✓d�^�dept - ater table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ t Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE -C) No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number 7 SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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, an4l 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 workman's compensation laws of California."Contractor'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 empl6y persons subject to workman's compensa- tion laws of California." The applic must call for al a uired i pections. Complete drawing on reverse side. Signed Title: Date: r j F R DEPARTMENT USE ONLY 4 e, Application Accepted by Date _ Pit or Grout Inspection by Date Final Inspection by Date U✓ Additional Comments: Applicant - Return e11 copies to: Satz Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DDUE AMOUNT REMITTED CASH CK 4 RECEIVED BY DATE /PERMIT'NO. f E„i4.224alAEV.riNSl ` Ld - v i