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I APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION X601 E. HAZELTON AVE. , PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 952rr ( pFAMIT XP RES I YEAR FROM DA ED (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. ,d� 10 / � �Q. City T-+�' �' TLotSize/Acreage � 14 • C Job Address I . B 6 rp Z' Owner's Name �'7 M V Q �� Address �- ��' Phone Z� 7 Contractor L� Address License No. hone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL . OT LL PITS/SUMPS a INTENDED USE TYPE OF WELL P ,�,L E NS U 1 I 1 S n Industrial ❑ Open Bottom ❑ Man c a. o EI cav t n Dia. of Well Casing C1 Domestic/Private ❑ Gravel Pack C7 r cy Specifications i I'1 Public 1-1 Other f 1 D � CO.. of �G�tt u[it may Seal � Type of Grout I i Irrigation �.Approx. Depth IMF , Oing �jOBi Mall Repair Work Done ❑ Type of Pumptt',{' " "4terepth tJ� �lork Dane !� C15 Well Destruction C3 Well Diameter Depth Filler Material & Depth Q TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION l DESTRUCTION I I IN. septic system permitted it public sewer is 4 . available within 200 feet.I 'V Installation will serve: Res' ence L Commercial Other Number of living units: .,. i tNumber of bedrooms Character of soil to a depth of 3 feet: A—k 13 Y Water table depth SEPTIC TANK. ❑ Type/Mfg &X Capacity_ 19,0 o No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE M-'-No. & Length of lines ? Z'" © III " 7 - __ T9tal length/sire 7► L""'ti" `''[�'7 FILTER BED C3 Distance to nearest: Well ► (3 -- Foundation 0 Property Line o SEEPAGE PITS I I Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line 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, an 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 t1' employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature canifies 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 applican a, -IX re d inspections. Complete drawing on reverse side. fSigned Title: n��p - _ Date: FOR DE ARTMENT USE ONLY 4 Application Accepted by _ Date ,bArea Pit or Grout Inspection by Date Final Inspection by Date 4 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health'Permit/Services 1601 E. Hazelton Ave., P O,Box 2009, Stockton, CA 95201 FEE iN AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE CPERMIT N0. • EH 13-24 IR t0� t0� �� dO t� Ld^ (J� EH A-26