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APPLICATION FOR PERMITr � SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ^^,,•.,, - ENVIRONMENTAL HEALTH DIVISION `o 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 #� P O BOX 2009, STOCKTON, CA 95201 t1i PMWIT EXPIREg I YEAR EROM DATE (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 trade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address _30 ,0 City Lot Size/Acreage Owner's Name �r15d'/ Address Phone / Contractor Address C2 49 License No. Phoney TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C] OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. —P#i9P-.-0a j FOUNDATION AGRICULTURE WELL ELL PITS/SUMPS I _ I INTENDED USE TYPE OF WELL PROBLEM AREA UCTION SPECIFICATIONS n industrial ❑ Open Bottom ❑ M Dia. of Well Excavation Dia. of Well Casing Ca Domestic/Private L1 Gravel Pack Tracy Type of Casing Specifications Il Public I;1Othe n Delta Depth of Grout Seal Type of Grout I I Irrigation _,.Approx. Depth [ I Eastern Surface Seat Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth �t Depth Filler Material 8 Depth 1W, TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTIOlNo septic system permitted if public sewer is available within 200 feel.I 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. 0 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 Sire Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS El I hereby certify that I have prepared this application and that the work wilt 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 taws of California." The applicant mu call for all requlr i ct' a. Complete drawing on re arse side Signed Title: Date: _-5-a_3 FPR DEPARTMENT USE ONLY Ap ation Accepted by AAAI Date __ ` ;,9 Area Pit or Grout Inspection by ___ Date Final Inspection bv,�� _ Datr�~3 C 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY CK DATE PERMIT'NO. OA i EH 14-2 IREV.t i n 5r * C7 1 1— 113 1