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APPLICATION FOR PERMIT ' I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOR 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FRAM 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 1862 and the Rules and Regulations of San Joaquin County.Public Health Services. VJob Address 4 j City Lot: Size/Acreage lC 1 l C) Owner's Name 7 l� Address �Z��l Z -- aan r a� - ---------- Phone a 6 d0 Contractor C7Wt 1 ,, Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑---. SYSTEM REPAIR C} OTHER ❑ Monitoring Well G7 MSTANC REST:'I.SEATIC,TANK SEWER LINES DISPOSAL FLO. PROP. LINE FO AGRICULTURE WELL OTHER WELL SUMPS INTENDED USE STYPE OF WELL PROBL CONSTRUCTI IONS C! Industrial ❑ Open Bottom ❑ Mantec Ea. o xcavation Dia. of Well`Casing Cl Domestic/Private ❑ Gravel Pa _ Tracy_ T__� Type of-_,Casing__ Specifications Il Public er., n Delta Depth of Grout Seal Type of Grout E I I Irrioation _.Approx. Depth I I Eastern Surface Seal Installed by ! Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth i Depth _ Filler Material & Depth } TYPE.OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION t I DESTRUCTIO I (No septic system permitted it public sewer is available within 200 feet,) Installation will serve: .Residence_ Commercial_____ Other : .---- ---— Number of living units: Number of bedrooms 1 Character of sail to a depth of 3 feet: ! Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ _ t Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total L dtliTsize FILTER BED ❑ Distance to nearest: Welt Foundation Property Line SEEPAGE PITS I I Depth Size Number i SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby cenify 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 taws of California." ' I The applicant must Celt for all required inspections. Complete drawing on reverse side, '�IlSi ned X�, r � .�..,.._. �r7 g Title: '�-�-s�� Date: FOR DEPARTMENT USE ONLY r I Application Accepted by _Date' Area: Pit or Grout Inspection by _ Date Final Inspection by Dat Additional Comments: r Applicant - Return all copies to: San,Joaquin County Public Health ,. 1 Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE/ AMOU,[NTr REMITTED GASH RECEIVED BY DATE PERM17'NO. EH1 -24IREV.iinss EH 114.26 l