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f � APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES / 1 44ENVIRONMENTAL HEALTH DIVISION 5 N SAN JOAQUIN, PHONE (209)468-3420 I P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (Complete in Triplicate) Application is hereby made.to San Uoaquin County for a permit to construct and/or install the work herein described. This application is made in cotpliance ?rith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Servici+es . Job Address II'PlCity Lot Size/Acreage �i r � Phone 6' Q� /0 Owner's Name dress Contractor d _ nse No. Phone YPE OF WELL/PU P: NEW12 LL P DESTRUCTION ❑ Out of service Well ❑ PUMP INSTALLA ION ❑ �` S EP i OTHER ElMonitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK �5 � I�li � sOSAL FLD. PROP. LINE FOUNDATION AGRI ULTUM-WELLOVViL T E WELL PITS/SUMPS VV INTENDED USE TYPE OF WELL L A"" U TI ULU . FFCIFICATIONS C7 Industrial ❑ Ogen Bottom Man Erb Dia. of Well Casing 17] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public rl Other k Cl Delta - Depth of Grout Seal~ Type of Grout Q` 1 1 Irrigation _Approx. Depth I I Eastern Surface Seal Installed by N Repair Work Done ❑ Type of Pump H.P. State Work Done Well"Destruction ❑ Well Diameter f Sealing-Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I k REPAIRIADDITION I I DESTRUCTION (No septic system permitted if public sewer is i available within 200 feetJ Installation will serve: Residence— [Commercial! Other Number of living units: Number of bedrooms Character of toil to a depth of 3 feat: Water table depth SEPTIC TANK. ❑ Type/Mfg j Capacity ¢ No. Compartments PKG. TREATMENT PLT.❑ € Method of Disposal Distance to nearest: Well Foundation Properly Line LEACHING LINE 0 No. 6 Length of lines Total lengthtsize FILTER BED ❑ Distance to nearest: Well Foundation Property Line ,j SEEPAGE PITS I I Depth Sire Number SUMPS Ll Distance to'nearest, Well Foundation Property Lint " DISPOSAL PONDS ❑ 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." Contractors hiring or subcontracting 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 st 11 for all required 'nspoctiont. Cpmplete drawing o raverse side. 1 ,g Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by5;9�_ _ Date � Are Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ` �1 Applicant - Return all copies to: San Joa in County Public Health Services j Environmental Health Permit/Services IJ 445 N San Joaquin, P 4 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO . EH 63.71 IIIEY. n 6i 5 11 CJ o EH 11.76