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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOR 2009, STOCKTON, CA 95201 1 <br /> PERMIT TXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in comyliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 211e 21,i city _'uT Zit Lot Size/Acreage 216 ,ACkrs <br /> Owner's Nameaxi e_L , ,&T A L OZ! 94L41,ddrass 5,�2-3- V�6 _ Phone <br /> Contractor 'n 1LU_t40Ota Address License No. 7- r Phone <br /> TYPE Of WELL/PUMP; NEW WELL O WELL REPLACEMENT O DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEMREPAIRC ~OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUN I E'V9! 'L � OTHER WELL PITS/SUMPS _ <br /> i INTENDED USE TYPEFF <br /> 1NE� LM 0 R PECIFICATIONS <br /> G industrial ❑ Open Bo`qopmr `3 fes❑ [v1 ty��caxa �r�9( Vitra �o�f/Wall E ovation Dia. of Well Casing I <br /> r] Domestic/Private ❑ Gravel P5c3�rlifl6 rr[nJ r y`�� F'�(,two-;4Cff Sir _; Specifications I <br /> t E <br /> I'l Public (-I Other work bRin giffiPl d Wm0gote4eai Type of Grout <br /> VI I Irrrpatron _.App,l�j gp j a tern k1 ft (�q�pS qI I tailed by IF <br /> Repair Work Done U Type of PuRfrU""�' - � Utki E�t'ilalU!I ,State Work Done <br /> Well Destruction O Well Diameter Sealing #daterial & Depth <br /> / Depth Filler Material & Depth J <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> L+ sable within 200 feet-I <br /> Installation will serve: Residence Commercial_ OtherK�1 <br /> Number of living units: _Z_ Number of bedrooms r 3 . 1. �� i <br /> Character of$oil to a depth of 3 feet:. x r d Water table depth <br /> r <br /> SEPTIC TANK. J6 Type/Mfg l�..';r! Capacity—f 2_640 No. Compartments .r <br /> PKG. TREATMENT PLT.0- ,. L, Method of rsposal ?. <br /> ( v Distance to nearest:. Well Foundation f L Property Line _ <br /> LEACHING LINE 0 No. & Length of lines yok, 72 Total length/size ' <br /> FILTER BED. Distance to nearest: Well _ Foundation t2 Property Line1wn SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Lt Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS OI hereby certify that I have.prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stat <br /> rules and regulations of the San Joaquin County +- . + .. I <br /> 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 <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or suo-contracting sionature <br /> 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- <br /> tion laws of California." <br /> The applic t must call for an required inspections. Complete drawing on reverse side. <br /> Signed X r Title: flew-� Date: <br /> FOR DEPARTMENT USE ONLY i <br /> Application Accepted by —4. a .s.�.� Date ;,mss <br /> �- C%_L}t Area <br /> Pit or Grout Inspection by Date Final Inspection by Data <br /> Ad0ional Comments: '~ <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services r <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton. CA 95201 l <br /> INFON-TIL100 <br /> OUN^T�^D;UUE AMOUNT REMITTED CASN RECEIVED BY DATE PERMIVNIO�, f <br /> • EN 1`28EH 13-24 IAtEV rinSl a�� 3 <br />