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t APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I ENVIRONMENTAL 'HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 I P 0 BOR 2009, STOCKTON, CA 95201 . PFJWIT EXPIRES 1 YEAR -FRMDATE ISSUED 1 (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This I. application is made in compliance with San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address -� .�u,S,QA2 p /A !�� _ _-- City 15 A) tot Sine/Acreage 1DoX 420 f Owner's Name ON 6 ddA Address S 4 Phone -Z Z 4- Contfactor La YD —&, i0,05 aL Address_ 7 Al� A-tl— License No. 6 Phone 4 e Y-3 r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 0 DISTANCE TO NEAREST: SEPTIC TANK EWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION A RICULTURE W OTHER WELL PITS/SUMPS } INTENDED USE TYPE OF WELL PROBLEM A A C STRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ AAA of Well Excavation Dia. of Well Casing C7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications - I'1 Public C7 Other I n Delta th of Grout Seal Type of Grout I I Irrigation App(ox. Depth I I E ern Su a Seal installed by Repair Work Done U Type of Pump, H.P. State Work Done_ Well Destruction ❑ Well Diameter -Sealing7Materia & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION: REPAIR/ADDITION I I DESTRUCTIO _l_ILYo_�a^+.�_rsu�tR�^P fitted if public sewer is i' available within 200 feet.) Installation will serve: Residence�� Commercial_ Other "7-oFEXIS7�/✓G �ECo�la 1 , Number of living units: _L Number of bedrooms P1210k'-Tt� r'�}7�. Character of soil to a depth of 3 feet: �'��Y ___ __ _ _.. a pt SEPTIC TANK. W�Type/Mfg C�— G 'C- _ . Capacity -IL60 No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well -7 Foundation fQ Property Line LEACHING LINE No. & Length of lines ��` Total length/size J®O FILTER BED ❑ Distance to nearest: Well /Q� Foundation_ 1457` Property Line �� 7 SEEPAGE PITS VK"Depth cAC ` Size 4---1- — Number SUMPS Cl Distance toynearest: Well AW Foundation ZOQ Property Line. f 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 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,.)shall employ persons subject to workman's compensa- tion laws of California." , The applicant must call for all required inspections. Complete drawing on reverse side. i Signed }( t- Title: _ .. Date: EPARTMENT USE ONLY c �, Application Accepted by 44 � t _k c Date Ars Pit or Grout inspection by Date Final Inspection by Date Additional Comments: { Applicant - Return all copies to: San Joaquin County Public Health 1T Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P.0-By 2009, Stockton, CA 95201 FEE1 INFO AMOUNT DUE AMO(UjNT REMITTED ASH RECEIVED BY DATE PERNIIT�,'/NO.- , . EN 17-24IREV.1/N5) EH 14•26 }