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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 200911 STOCKTON, CA 95201 (209) 468-r3447 R (Complete in Triplicate) Application Is hereby made to San Joaquin County for a permit to construct and/or install the vork 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. e_," � Job Address �� City ' �j["�I 4!m' et Size/Acreage / .4C- Owner's Name Address Phone ,q3 7.-V Contractor _I Lat1D g�• VjWg2 Address 7 4 .i<}J��.BE_.2 e& License No. � �-7G Phone r 347 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT'❑ DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REP ❑ OTHER 0 Monitoring Well 0 DISTANCE TO NEAREST: SEPTIC TANK SE R LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRI LTURE L OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA ONSTRUCTION SPECIFICATIONS n Industrial �❑ Open Bottom ❑;Ma- ca is, of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack 0 Ty of Casing Specifications M Public C1 Other ❑ Dept of Grout Seal Type of Grout 0 irritlation Appror, Depth Eastern Surfac Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Materis.1"s,Depth Depth Filler Materi 1 Z Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION LI v DESTRUCTION Ci 1No septic system permitted if public sewer is / evailable'within 200 feet.) Installation will serve: Residence r Commer6iei _ Other Number of living units: Number of bedrooms .�. Character of soil to a depth of 3 feet: _ 5.4�/�-, .tea ? _ __.-Water table depth SEPTIC TANK 'W Type/Mfg- Capacity No. Compartments PKG. TREATMENT PLT. 0 ` . Method of Disposal 'Distance to nearest: Well My Foundation Property'Line � LEACHING LINE No. & Length of lines- Totil length/sizes FILTER BED n Distance to nearest: Well es Foundation 40,� Property Line f� r . SEEPAGE PITS Ii Depth Size Number SUMPS LI Distance to nearest: Wel Foundation .'Prop" Line DISPOSAL PONDS ❑ I hereby certify that I have ptepared 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 inspections. plate drawing on reverse side. Signed Title: L( _ Date: 2- FOR FOR DEPARTMENT USE ONLY i !L �---- -- Application Accepted by Date o`er ` ` Area Pit or Grout Inspection by Date Final Inspection VY 'Date 2 AUC Additional Comments. Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON. CA 95201 INFO FEE AMOUNT DUE AMOUNTREMt'rTED CASH RECEIVED By DATE PERMIT'N0. 11111y E '4 H- ..2e - 1 11