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i APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P O BOIL 2009, STOCKTON, CA 95201 No PERMIT EXPIRES 1 YEAR FRQM DATE ISSED (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. f Y Job Address' _ ijQ AlL%T Git�y of Size/Acreage 5Q Owner's Name Address _2 r - Phone A Conlraclor__Ii_; Address License No. Phone TYPED UMP: NEW WELL LJ WELL REPLACEMENT Ci DESTRUCTION ❑ Out of Service Well ❑ INSTALLATION El ; SYSTEM REPAIR ❑ OTHER ____Nw i�oring Well ❑ DISTANCE TO NEAREST: SEPTIC TA SEWER LINES DISPOSAL FI PROP. LINE FOUNDATION ICULTURE �i; WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA TIONSPECIFICATIONS I n Industrial ❑ Open Bottom ❑ Dia. of Wei tion Dia. of Well Casing 1l Domestic/Private ❑ Gravel P .❑ Tracy Type,of Casing_- Specifications j I'1 Public or n Delta Depth of Grout Seal Type of Grout 111 I Irrigat' �.Approx. Depth 11 Eastern Surface Seal Installed by epair Work Done L3 Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADOITION I ! DESTRUCTIONINo septic system permitted if public sewer is y a available within 200 feet.l i Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms r �YYY Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK: ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. El Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Ci Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS 0 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, 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, l 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 st cdlt or all required inspections. Complete drawing on reverse side. Signed X Title: Date: �,_ JFORJREPARTMIENT USE ONLY t PP Application Accepted by - Date -_`t° 9/1 Area S9 to Pit or Grout Inspection by Date Final Inspection by i A AAData Additional Comments: Applicant - Return all copies to: Sen 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 I CV CASH RECEIVED By DATE PERMIT N0. INFO + EH 13.24 1REV.I/n 5)SP 1N ,00 00 S—)4 WEH 14-M