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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �- 00 ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 Q P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I YEAR FROM DATE_ ISSUED (Complete in Triplicate) Application is hereby made to Ban Joaquin County for a permit to construct and/or install the vork 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 Services. Job Address La' City C Lot Size/Acreage C-1 Owner's Name MTV , polka Address �aM40— Phone � Contractor ddress6`L i `lr- —License No. Phone TYPE OF WELL/PUMP: NEW'WELL71r,, WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION [ SYSTEM REPAIR ❑ OTHEP 0 Monitoring/Well K 0 DISTANCE TO NEAREST: SEPTIC TANSEWER LINES DISPOSAL FLD.ffPROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA IOjV ❑ Industrial �Gravel pen Bottom ❑ anteca Dia. of Well Excavati rr Dia. of Well Caain omestic/Private Pack racy Type of Casing_ SYcifications ther f✓✓l Delta Depth of Grout Seal �4ype of Grout r I'1 Public \ I 1 Irrigation Jk7Approk. Depth I I Eastern Surface Soul Installed by_ of 4 -- - Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Tiller Material 4 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I i INc septic system permitted it public sewer is available within 200 feet.1 Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Sire Number (� SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 13 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 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 employ persons subject to workman's compensa- tion laws of CalifIl The al:Cast tali for . spgctions. Comple drawing on a arse si Signed Title: Date: �3 R DEPARTMENT USE ONLY Application Accepted by C101..4 Data — ; 3 Area V Pit o►!rou nspection by Date Final Inspection b Dats Additional Comments. ! Applicant - Return.-ill copies to: San Joaquin County Public Health Services ' Environmental Health Permit/Services 445 N San Joaquin, P O Sox 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED I CK RECEIVED BY D TE PERMIT'NO. t�IN�f� EH 13da IIIEV. i n 6Y f 1/ EH 1476 V"