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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 12ERMIT EXPIRES 1 YEAR FROM DATE_ ISSN (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. Job Address rpe a '� � City !",— era_ Lot Size/Acreage Owner's Name ,- /�}} ,f� f`s Address lir dif� s r AKN one Contractor d A0!fie � Address /�r?� �a��'q"4r !/iY License No. �Q�� Phone �3 g /� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D Out of Service Well Cl PINSTALLATION l ) SYSTEM REPAIR C1 OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPI f K SEWER LINES DIS PPS*t PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBL TRUCTION SPECIFICATIONS n Industrial 0 Open Bottom © M Well Excavation Dia. of Well Casing [7 Domestic/Private ❑ Gravel Pack Tracy Type o Specifications I"I Public Cl Othe fl Delta Depth of Grout Type of Grout I I Irritation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work D Type of Pump H.P. State Work Don _ Well uction ❑ Well Diameter Sealing Material & Depth q Depth Filler Material & Depth `V TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADOiTION I DESTRUCTION I 1No septic system permitted it public sewer is available within 200 feet.! k Installation will serve: Residence_ Commercial— Other `\v Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: _.._!C�6 d __ ___ Water table depth SEPTIC TANK. ❑ Type/Mfg C1_Jy9W4- ^T Capacity 4�A00 No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal r Distance to nearest: Well "AFB Foundation 247 Property Line AL r LEACHING LINE Cl No. & Length of lines Total length/size (� FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation . _ Property Line DISPOSAL PONDS Cl 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, I 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. Signed X ��,_ + Title: Q" C?A_ _ Date: 1�-- 3/- Fa =eUSET ONLY Application Accepted by Date �� t Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant _ Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P ox 2009, Stockton, CA 95201 INFO FEE AMOUNT DUE AMOUNT�R7ElMITTED SH RECEIVED BY PATE PERMIT NO. r fH 13-24 4REV.t/n sl �V v 3 L/V L�� EH 14-2e ✓✓✓ ` !