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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC aEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2069, STOCKTON, CA 95201 (209) 468-3447 REMIT EXPIRES I R PROM-DAIE ISSUED, (Complete in Triplicate) Application is hereby m>sde.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. Job Address -4 7 A —A ,O ,,,.,,,,,__ City t416 1P Lot Size/Acreage 2z' Owner's Name 6'K 5 �, Address 0 v Phone 1 Contractor _-_____A111_ mfr Address License No. Phone TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ C-R—cr' Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DI FLD. PROP. LINE FOUNDATION AGRICULTURE WEL OTHER WELL PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS n Industrial C1 Open Bottom ❑ eca Dia, of Well Excavation Dia. of Well Casing U Domestic/Private 0 Gravel Pack OLI Tracy Type of Casing Specifications .._ M Public El Orhe ❑ Delta Depth of Grout_Seil,T" _ �'""""''Typa�t Grout �—. Ci hripation Approx, Depth ❑ Eastern Surfaci Said Installed by ' Repair Work Done Type of Pump H.P. State Work Done _ Well Desir ' n ❑ Well Diameter Sealing Material i Depth D Depth Filler Material i Depth TYPE OF SEPTIC WORK:. NEW'INSTALLATION❑ REPAIRIADDITION CI DESTRUCTION CI (No septic system permitted if public saw—of is ? available within 200 feet.) Installation will serve: Residence r Commercial Othe , r, Number of living unite: --- Numberof-bedrooms Character of soil to a depth of 3 feet: f Water table depth SEPTIC TANK. ❑ Type/Mfg `f Capacity Qa No. Compartments �— PKG, TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well D Foundation Y12 Property Line ZSR LEACHING LINE No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well f �_ Foundation �._ Property Line i SEEPAGE PITS 11 Depth `� Size- /r /Z) Number 2 SUMPS Distance to�neerest: Well O If Foundation D * Property Line�. DISPOSAL PONDS ❑ :a, 6 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 hot employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature cenifies 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 applicant ust call for al required inspection Complete drawing on reverse side. Signs V � Title: �(� � Date: `/ �Cd R AtARTMENT USE ONLY r Applicatlo Accepted by Date a 6' Pit or Grout Inspection by = Date Final Inspection by Dats 4 Additional Comments; Applicant — Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES t ENVIRONME14TAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 98201FEE ; INFO AMOUNT DUE AMOUNT AEftitITTEp CASN RECEIVED BY DATE PX 0 ERMIT NO. 1124 , ( 0{7 l ��0 H