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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ((''�� 1601 E. HAZELTON AVE. , PHONE (209)468�2,� P 0 BOX 2009, STOCgTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. L/.1f /1 (' //� t, mss^ ^' Job Address .l 4 �. City'-��--! Lot Size/Acreage �10 1 Owner's Name r` n Address / fYl ` ltf Ll Phone Con rector Address License No. Phone VPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ onitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESL FLD. PROP. LINE FOUNDATION AGRICULTURE OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLE CONSTRUCTION SPECIFICATIONS C.l Industrial ❑ Open Bottom an lice Dia. of Well Excavation Dia. of Well Casing F) Domestic/Private ❑ Gravel ❑ Tracy Type of Casing Specifications I'I Public - ther ❑ Delta Depth of Grout Seal Type of Grout Irrigation _Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material L Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 I DESTRUCTION NL(No septic system permitted if public sewer is vailable within 200 feet.) Installation will serve: Residence_ Commercial_ Other Na Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth f� SEPTIC TANK Cl Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 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 11 Depth Size 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 workmen'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 applic mu call f all required inspec t. mplete drawing on reversed sii�de,. / y Signed X Title: 19 -,e->— Date: 455' " (/V ////7 FOR D ARTMENT USE ONLY Application Accepted Dy r'` Date rArea_Y Pit or Grout Inspection by 9 Date mal Inspection bv +/U Date Additional Comments: 9n Q1�IlAnt7 1 rn Applicant - Return all copies to: ban Joaquin County Public Health Services, Srvironmental Health Permit/Services 1601 E. Haselton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT NO. • EH 13 24 i/xs) :bS -� ' 1 0&H41 �� r _ 7�� FH is b L