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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES X YEAR FROM DATE ISSUED j it (Complete in Triplicate) F Application is hereby made.to San!Joaquin County for a permit to construct and/or install the work herein described. This application is rade in compliance 4ith San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Servicies. 0 Job Address + City Lot Size/Acreage o� Owner's Name �� 1 _ Address Phone o `� Contractor !� AddressLicense No. /I7z yrs Phone , '107 TYPE OF WELL/PUMP: NEIN WELL ❑ WELL REPLACEMENT F DESTRUCTION LK Out of Service well ❑ PUM7ANgo SYSTEM REPAIR 0 OTHER 11 Monitoring Well DISTANCE TO NEAREST: SEPSEW ES DiSPOS PROP. LINE r F,OUGRICULTURE L ER WELL PITS/SUMPS INTENDED USE � TYBLE REA UC SPECIFICATIONS Cl Industrial I ❑ Opan �ia +tif Well Excavatio Dia. of Well Casing �,M Domestic/Private1Gracy Type of Casing_ Specifications F) Public L.1-Ofelta Depth of Grout Seal f GrLL out I { Irrigation Approx. Depth l 1 Eastern '• `'Suriac_s Seal Installed by 1 —� - r Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Materiel & Depth + Depth Filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION [ I REPAIR/ADDITION I I, DESTRUCTIOINo septic system permitted if public sewer is available within 200 leet.l Installation will serve: Residence Commercial— Other ` Number of living units: Number of bedrooms I Character of soil to a depth of 3 feet: I Water table depth y�'r SEPTIC TANK. 0 Type/Mfg'f Capacity No. Compartments sr PKG. TREATMENT PLT.❑ iMethod of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size j FILTER BED ❑ Distance to nearest: Well Foundation Property Line V SEEPAGE PITS 11 Depth � Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i 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 Joaquirilcounty 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: '9 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 applicant must/call forailrequired inspections. Complete drawing on reverse side. Signed X_ Er �} a, L ,N _ Title: �Gv2rJ✓ Date: _.._ F R DEPARTMENT USE ONLY X 111 A- -- ... . _ Application Accepted by �j`` `f►A rb Date ea Q �' Pit or Grout Inspection by f Date .Final Inspection b Date Additional Comments: f Applicant - Return all copies to: San Joaquin County Public Health Services I� Environmental Health Permit/Services j 445 N San Joaquin, P O Box 2000, Stkn, GA 95201 IFEE AMOUNT DUE if AMOU T REMITTED RECEIVED BY OA3E PERMIT'NO. . 1113.24111r/x51 C1 ra A8�� : EH 1420 I//�)