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APPLICATION FOR PERMIT cc SAN J'OAQUIN COUNTY PUBLIC HEALTH SERVICES O � ��1 au�nea( ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420� �� P O BOX 2009, STOCriTON, CA 95201 W 0 Ip cit tf'� PERMIT WIRES 1 YEARFRQM DATE1.9SUED (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 1662 and the Rules and Regulations of San Joaquin County Public II11 Health Services!`._' ``��, •C Job Address r'7�'"c �S 440 lcw�J _ City c7{ Tq � Lot Size/Acreage Owner's Name !mac-r �' CLQ J Address ty�C """`ti]- Phone4o o -e)� -A Contfactor_ !" --�y� Address License No. Phone TYPE OF LL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: aK TANK SEWER LINES DISPOSAL FLD. P LINE FOUNDATIO AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PRO SEA CONSTRUCTION SPE IONS n Industrial ❑ Open Bottom ❑ Manteca of Wavation Dia. of Well Casing F] Domestic/Private ❑ Gravel Pack 0 Tracy e of Specifications Fl Public (-1 Other [� Dek Depth of Grout Sea Type of Grout I I Irrigation Approx. Dept Eastern Surface Seal Installed by Repair Work Done 0 Type of P H.P. State Work Done r Well Destruction ❑ iametet Sealing Material &-Depth Depth Filler Material & Depth TYPE O TIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1K INo septic system permitted if public-S-6taLer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living unite: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal f Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Property Line SEEPAGE PITS 1 I Depth Sire Number SUMPS LI Distance to nearest: Well Foundation - Property Line DISPOSAL PONDS ❑ 1 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 jnspWicns. Complete drawing on reverse ssiride�-.�' �. r Signed X__-_..1_ _ Title: ! �'� Date: / FOR.DEPARTMENT USE ONLY Application Accepted by ,^�„ ,.,,,.,_, Date Area Pit or Grout Inspection by Date Final Inspection by t Date 7 Z Additional Comments: 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. . EH 1 3-24(REV.i/X511 y (0 9 t,},_W �2 �� EH t{•2a i