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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 !I P 0 BOX 2009, STOCKTON, CA 95201 ii 29MIT 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 in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin county Public Health Services. I ` Job Address .l A'' - -- -- City Lot Size/Acreage �/ X Y22___ ^ Owner's Namel — address G'�`�V _I_.11_ _ y Y:, Phone -_ .I f W `� ( t C0ntr3CI0( + f_ Address 1/'Vs-J License No. a ni Phone r ` TYPE OF WELL/PUMP: f NEW ELL ❑ �IWELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑PUMP INSTALLATION ❑ SYSTEM REP ❑ OTHER ❑ Monitoring WellDISTANCE TONEAREST: SEPTIC TANK SEWLINES DISPOSAL FLD. PROP. LINE I1. FOUNDATION AGRLTU ELL OTHER WELL PITS/SUMPS INTENDED.�USE TYPE OF WELL PROBLEM A13. CONSTRUCTION SPECIFICATIONS _J I n Industrial ❑ Open BottoZlEastern Dia. of Well Excavation Dia. of Well Casing V ❑ Domestic/Private ❑iGravel Pack Type of Casing Specifications I'] Public fa Other.f Depth of Grout Seal Type of Grout l I III _.Approx�DSurface Soulal installed byRepair Work Done v Type of PumP �`� ` State Work Done_ p.3 t Well Destruction ❑ Well Diamet Sea ing Haterlik&^Depth E .. r, Depth ?� Filler Material & Depth [ j TYPE OF SEPTIC WORK: NEW INSTALLATION.! REPAIR/ADDITION I I DESTRUCTION I I (No°septic-system permitted it public sewer is CA available within 200 feet.) tnstaliation Dill serve: Residence v Commercial,7-0` ther A Number of living units: Number of bedrooms ` t Character of' to a depth of 3 feet: f 4 Water tablt' depth ` ' 4 SEPTIC TANK! ❑ Type/Mfg `6 Capacity .t No. Compartments PKG. TREATMENT PLT. ❑ �` ` _ / Methodhof=Dispo al .c r J Distance�10 nearest: Well . Foundations Property Line i LEACHING LINE D Pb,`` &'Length of lines T tai length/size' 441* FILTER BED t ❑ Distance to nearest: Well oundation- ,Property Line { s SEEPAGE PITSI If Depth Size 0 F ,R`No.'�tuber ' lA SUMPS Ll Distance ton rest: Wellundation i Property Line- I DISPOSAL PONDS ❑ _a�L I hereby certify'kIhat I have prepared this application and that the work will be done in accordance with San Joaquin countyJordinances, state laws, and rules and regulations of the San Joaquin County * l 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;dr subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall aniploy persons subje'ct o workman's compensa- tion laws of California." The applicant ust call for required i spections. Complete drawing on reverse side. Ih ~ ' Signed X Title: Date+ l d~a3� Iy l j = T f l FOR DEPARTMENT USE ONLY Application Accepted byAA;�ZDateArea o Pit or Grout Inspection by Date Final Inspection by Dat+f A g� Additional Comments; �i Nq i Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 �p FEE AMOUNT DtJE AMOUNT REMITTED CK RECEIVED 6Y DATE _ PERMW N0._ _ -INFO --GASH. - q q . EH t324{REY.i i x m, T ��a �0��3`W Y� �� ne EH i4•Ie I�