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APPLICATION FOR -PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION l 1601 E. HAZELTON AVE., PHONE (209)468-3420 P 0 BOR 2009, STOCKTON , CA 95201 V` PEAMI:C EXPIRES 1 YEAR FROM DATE ISSUED (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 theRulesand Regulations of San Joaquin County Public Health Services. 3 1 S t�ot Size/Acreage Job Address r 22��0o pR1 &5T � ° ' �o x 'f237 S��"'` yA1. Owner's Naind0 S T 1) L� A � �� Ad rens 9L f O-cl t �� R�! Phone t� 4 �'�/G � �� afANZ _S F'4I RFI' p n p P R fV �c No.,,Y�Pf�one� Contractor , -(f Address -s n?g )� c� rise TYPE OF WELL/PUMP: EW WELL ❑ WELL REPLACEMENT 'L1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTAL ION O SYSTEM REPAIR O OTHER G Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �____._ DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENOED USE TYPE OF WELL PROBLEM CONST CIFICATIONS D Industrial O Open Bottom ❑ Mante is. of Well Excavation _ Dia, of Well Casing Fl Domestic/Private ❑Gravel Pack Tracy asing Specifications Type Casing- VI Public C r ❑ Delta Depth of ut Seal Type of Grout i I Initiation Approx. Depth 11 Eastern Surface Seal Ins ad by Repair ork Done 0 Type of Pump H, P. State Work Done _ Well Destruction O Welt Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I ; DESTRUCTION INo septic system permitted if public sewer is available within 200 feet.I Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water tante depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ _ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. b Length of lines f Total length/ size FILTER BED O Distance to nearest: Well Foundation Property Line s SEEPAGE PITS 11 Depth Size" _ �l Number SUMPS LI 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. I shall not l M employ any person in such manner as to become subject to workman's compensation laws of California," CDniractor'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 ust all for all required inspections. Complete drawino on reverse side. Signed X_ � ,! lTA4 Title: o� %� Date: f F DEPARTMENT USE ONLY Application Accepted by Pit or Grout Inspection by Additional Comments: . , ,& a--v_oC z, /4ate 4.4 -�e rr a Date Final Insp ction by a Gc110 S, Applicant - Retura all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services +� �f 1601 E. Hazelton Ave., P O� 2009, Stockton, CA 95201 . EH 11 -II IREV. r/e5 EH .!•Ie Area &-.;,4,-i a c Da e .6 y Gam- s tFEE PUNT DUE AMOUNT REMITTED A RECEIVED BY DATE PEAMiT NO.t'7 LFr�oq, `�10_ — p IV