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APPLICATION FOR PERMIT , SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT 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 1n compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address A-1, "AfA City e Lot Size/Acreage Owner's Name �� Address '7,03 dAWET ter 5*0 Irq--Phon. qlS -1939 Contractor 11 407-m ,"'u, <,C�T��Address &MA04-10 License No. Phone 2% TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIONS ut of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE G FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial O Open Bottom �FAanteca Dia. of Well Excavation r/ Dia. of Well Casing O Domestic/Private O Gravel Pack_ ❑ Tracy Type of Casing �C� cfu Specifications I'l Public P.Other fl Delta Depth of Grout Seal Type of Grout 1 I Irrigation _.Approx. Depth I I Eastern Surface Sedl Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Wel Destruction Well Diameter Sealing Material i Depth Depth Tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION 1 I DESTRUCTION I I (No septic system permitted if public sower is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of sol to a depth of 3 fast: Water table depth SEPTIC TANK. O Type/Mfg Capacity No. Compartments ( (� PKG. TREATMENT PLT.O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. b Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 1 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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." Contractors 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 oforrl' The applica at cal fo� squired ' spm Complete drawing on r rse fide. Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted byDate ` q � Area Pit or Grout inspection by Date J� Final Inspection by - Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services O Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 IFOOP�9-7 EEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. ts•2s . EM 13.24IREV.i.,ss1 D a_l2- -� L0 a� y EM