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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 Ll� P O BOX 2009, STOCKTON, CA 95201 2 EXPIRES 1 YEAR FROM DA ED �/2 (Complete in Triplicate) G� J 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 Hea th Services. + � Job Address y City "� Lot size/Acreage x` �.� "r Owner's Name a 5 Address ' Phone on / }Cj,�'r I rr �j I 1l� dress License No.✓ Phon Contractor IU�� TYPE OF WELL/PUMP: NEW WELL CX41 EPLACE NT D DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ STEM EPAIR Q OTHER ❑ Monitoring well C7 DISTANCE TO NEAREST: SEPTIC TANK SEDISPOSAL FLD. PROP, LINE FOUNDATION AGLL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEMS RUCTION SPECIFICATIONS f7 Industrial ❑ Open Bottom ❑ Mantec . of ell Excavation Dia. of Well Casing fl Domestic/Private ❑ Gravel Pack ❑ Tracye of sing Specifications I'l Public Cl Other fl Deltath of out Seal Type of Graut I I Irrigation �.Approx. Depth I I Easternface Seat nstalled byWRepair Work Done ❑ Type of Pump State Wark DaneWell Destruction ❑ Well Diameter terial & D th Depth Filler Material S Depth G TYPE OF SEPTIC WORK: NEW INSTALLATION I I' REPAIRIADDITION I I DESTRUCTIONINo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units: 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 " Distance to nearest: Well Foundation Property Line .� LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line 1 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 cartifies the f wing: "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 alit rnia." The applic t m st ca for aI r quired ins tions. Complete drawing on reverse side. r /,►r Signed Title: ryWDate: [[ FOR DEPARTMENT USE ONLY Application Accepted by Date tiT Area Pit or Grout Inspection by Data Final Inspection by / Date%lets' 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 AMOUNT DUE AMOUNT REMITTED CK 11 RECEIVED BY DATE PERMIT'NO. INFO ASH_.r_ Z 6� ^f . EH 13.24(REV.t In 5) - �� Q 1-2 �0 ~(215 EH'14-1a gt6-12