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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 0 BOX 2009, STOCKTON, CA 95201 fREMIT EXPIRES 1 YEAR FROM DATE ISEUED r i (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 Colony Public Health SVvices. r --,Z-) - CLot Size/Acreage Job Address v - y - Owner's Name DA14 Lis Address 533 mg&5kASte` -- Phone • l i Contracto g A ` Address��? M+Falks License No. F Phone 7 Q TYPE OF WELL/PUMP: INEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION Out of Service Weil 0 PUMP INSTALLATION ❑ SYSTEM-REPAIR C1OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK 0 SEWER LINES DISPOSAL FLD. PROP. LINE fFOUNDATION AGRICULTURE WELL ' .OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manieca Dia. of Well Excavation Dia. of Well Casing t Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications I') Public 1.) Other tI n Delta _ Depth of Grout Seal , �" Type of Grout I I Irrigation —.Approx. Depth I I Eastern°moi ,y Surface Seal Installed by ' 3 E Repair Work Done U Type of Pumpt I H.P. tate W rk,D ne_ Well Destruction R1 Well Diameters - l i Sealing Material & Depth LAl 1 r, Depth S Filler Material & Deptti"""T TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIRIADDITION i I DESTRUCTION ttb 'septic "system permitted if public sewer is available within 200 feet.) Kfl Installation will server Residence_ Commercial Number of living units: L. Number of bedrooms ' t Character of soil to a depth of 3 feet: t ! t Water table depth SEPTIC TANK ❑ TJpe/Mfg fAl l Capacity l No. Compartments PKG. TREATMENT PLT. ❑ .)'lj}rr � ^3 !� Method of Disposal Distance to nearest: Well t l Foundation i Property Line LEACHING LINE 0 No. & Length of lines_ f I I �Total'&ngth/size I FILTER BED n Distance to nearest: Wall`Ty 9undation J-Property Line s SEEPAGE PITSI I Depth I Size i ,:f<r' Numb+erl 4 ' x SUMPS Ll Distance to nearest: Well Foundation-fj _ : "'P,roperty Line DISPOSAL PONDS D '' i r _ i;r _ I hereby certify that I have prepared this application and that the work will be done in accordance'Wth San Joaquin county ordinances, state laws, and rules and regulations of the San Joaqu in I county f Home owner or licensed agent's signature certifies the following: "i certify that in the performance' f 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 taws of Califoinia." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in tha performance of the work for which this permit is issued, l`ahall employ persons subject to workman's compensa- tion laws of California." s' The applica t must call far II required inspections. Complete drawing on reverse side. Signed X Title: Date: EOR DEPARTMENT USE ONLY Application Accepted by ZDate t7 Area c- !� Pit or Grout Inspection by Date Final Inspection by ' Date Additional Comments: I t Applicant - Return all copies to: San Joaquin County Public Health s} Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DdE MOUNT REMIT-FED CK 11) RECEIVED BY DATE PERMIT*NO. CASH . EH 13-24(REV.+)8s+ r p� J -�• l 6Z3 EH 14•2e �-v