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I APPLICATIONIFOR PERMIT i SANJOAQUIN COUNTY PUBLIC HEALTH SERVICES I� ENVIRONMENTHEALTH DIVISION �� AL 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 If P O BOX 2009, STOCKTON, CA 95201 .i leC,� G If EXPIRES 1 YEAR FROM D ED (� _ 4cr�:�•- w!4 (Complete in Triplicate) I pplication ia•hereby made',to $an Yosquin County for a permit to constr tend/or insta3 h ork�herein Zia ^ cr application is made in compliance with San Joaquin County Ordinane No. L described. This 5 9 and 1$62 and the Rules and Regulations of San i I � 4 Job Address i et e,/ 'sN City - Lot Size/Acre e �� Owner's Nam Addres Ph9wd Contractor Vt Address, r c}� TYPE OF WELL/PUMP I� s License ffa.�Phone NEW WELL ❑� + WELL REPLACEMENT ❑ PUMP INSTALLATION ❑ sx DESTRUCTION ❑ Out of Service Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR OTHER ❑ Monitoring Well --- � SEWER LINES t FOUNDATION �. ` ----`----- DISPOSALtFLD. PROP. LINE ---�^ AGRICULTURE WELL— OTHER INTENDED USE `OTHER WELL PITS/SUMPS TYPE OF WELL PROBLEM AREA vTCONSTRUCTION SPECIFICATIONS i M Industrial ❑ Open Bottom ❑ Mangy taco Dia. of Was Excavation Dia. of Well Casing C7 Domestic/Private Cl Gravel Pack C7 Trac � .- � . f') Public y Type of Casing C7 Other Cl Delta } Specifications II(„t•Irrigauon 's �, Depth of Grout Seal Type of Grout { Approx. Depth I I astern] 5u ace Seai installed by ~# Repair Work Done ,1" Type of Pump H.P. = >. State Work Done Well Destruction ❑ Well Diameter Sealing Material &,Depth i Depth Filler Materiel & Depth Lly TYPE OF SEPTIC WOAK: NEW INSTALLATION I ] REPAIR/ADDITION f I DESTRUCTION I I (No seplfc system permitted if public sewer is # .. available within 200 feet.) tom, Installation will serve: Residence Commercial Other ` - Number of livingunits: r y Number of bedrooms ,a Character of soil to a depth of 3'feet: SEPTIC TANK. ❑;,Type%Mfg \ 'Water table depth r PKG. TREATMENT PLT. 0 t t . .Capacity a No, Compartments 4. Distance to nearest: Well - Method of Disposal I Foundation Property Line LEACHING LINE ❑ No. & Length of tines FILTER BED Total length/size i (1 Distance to nearest: Well Foundation \ d1, Property Line _ \\ SEEPAGE PITSI I l Depth Size Number SUMPS Ll Distance to nearest: Well Foundation DISPOSAL. PONDS ❑ T Propeny Line r 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 California." The appfic st all for ell require specti Complete drawing on reverse side. Signed d,. Title: Date: 0 FOR DEPARTMt:N7 U5E ONLY Application Accepted by I 1 Date —Z a Area I Pit or Grout Inspection by / r ' Date Final Inspection by Z Date�2�74Additional Comments: I� n q. 1 Applicant - Return all copies to: San Joaqula County Public H641thA i Services, Environmental Health Permit/Servicea° Fx�' 1601 E. Hazelton Ave., P 0 Box 2009. to, CA. 95201 ' FEE AMOUNT DUE AMOUNT REMITTED CK M.� lLL�111 INFO CASH RECEIVED BY EDATEEPERMIT'N EH 13-24IREV.riHs1 4.�.� GipIEH tf•2E !V — 1 -71194 �k 6.