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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 RNITE"IRES 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 with San Joaquin County Ordinance No. 549 and I 62 and the Rules and Regulations of San Joaquin County ,/Public �Health Sery ces Job Address .!I2 /.J -- CityXLot Size/Acreage Owner's Name Address 9/Z Phone t?lz- s/ Contractor A Address 0�— License No. Phone a—v ! TYPE OF WELL/PUMP: NEW ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTU E L OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM ARE ONSTAUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing [I Domestic/Private ❑ Gravel Pack D Tra pe of Casing Specifications I'I Public Ia Other n Delta pth of Grout Seal Type of Grout I Llrrigation ,11, —.Approx. Depth I I Eastern S rface Seal Installed by Repair.,Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler !Hater epth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR tADDITIO ' ES 'RUCTION 1 I INo septic system permitted if public sewer is �0Ilawtin eet. installation will serve: ResidenceCommercial ther � l, �D Number of living units: Number of bedrooms Z /,/) a Character of Goll to a depth of 3 feet: Water table depth a 06 SEPTIC TANK. ❑ Type/Mfg �` Capacitytz e� No. Compartments PKG. TREATMENT PLT. ❑ – Method of Di al Distance to nearest: Well U Foundation 6` Property Line , LEACHING LINE ❑ No. & Length of lines tai length/sire FILTER BED O Distance to nearest: Well .�. T Foundation Property Line SEEPAGE PITS 11 Depth lie�s, N bar : _ SUMPS LI Distance to nears Well r undation 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 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 taws 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,J shall employ persons subject to workman's compensa- tion laws of California." The applicant(Bust Cali fora squired insPections. Complete drawing on reverse side. Signed K V.43nA Title: __ _ _ _ Date: F R DEPARTMENT USE ONLY Application Accepted by Date Area �It Pit or Grout Inspection by Date J Finals Inspection•b Date l Additional Comments: a)n1 f��- 1�� 1 5 5 s I /rr 1 .,..------ Applicant – Return all copies to: San Joaquin ty Public Health Services, Environmental Health Permit/Services 1601 S. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT OUE AMOUNT REMITTEO CASH CK RECEIVED BY DATE PERMIT'NO. + EH 13-24 IREV.1/a 51 � ` 1591, EH 74.26 I�