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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE., PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES T YEAR FROM DATE I anEp (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 c00111311ance with San Joaquin County Ordinance No. 5k and 862 and the Rules and Regulations of San Joaquin County Public Health Services. \/Job Address -g- ivlzn2,",I r 7`2�0 Q I City lot Size/Acreage j / J%y�110k-ltP I< T r nereoy canny mat I nave 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 canify 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." Contractors hiring or subcontracting signature cert/applicanilcall : "I canify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tionis The for all r it in coons omplete drawing c averse side,SigTitle:(—a✓/'0//027 Date: FDEPARTMENT USE ONLY a Application Accepted by �,E( ��QA"A- IAti..L Date — ` Area 17, Pit or Grout Inspection by Data Final Inspection by Date Additional Comments: Applicant - Return all copies to: 8m Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 EN 324IaEV. v e m Err ta_M FEE NFO gMOUNT DUE AMOUNT REMITTED Owner's Name,��/!9 C`i Address �9 froom _fir_ Phon Contract `Address ^'y-- d,� l7�i /7/r2/1 /�[/'E� License NoffO `C � Phore 2 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Fl DESTRUCTION D Out of Se ice Nell ❑ CL �� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHE toring Well Cl DISTANCE TO NEARE C TANK SEWER LINES DISP PROP. LINE _ FOUNDA AGRICULTURE WEL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PR CONSTRUCTION SPECIFICATIONS 0 Industrial Cl Open Bottom anteca of Well Excavation Dia. of Well Casing r Domestic/ Private ❑ Grav ❑ Tracy Type of Specifications I"I Cher D Delta Depth of Grout Sea Type of Grout ��I�k _ Approx. Depth I I Eastern Surface Seal Installed by Re Done D Type of Pump H.P. State Work Dane _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION (I INo zeplic system parmitintl it public sower is available within 200 feet.) Insellation 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. Compartment, PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. 8 Length of lines Total length/size FILTER BED D Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r nereoy canny mat I nave 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 canify 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." Contractors hiring or subcontracting signature cert/applicanilcall : "I canify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tionis The for all r it in coons omplete drawing c averse side,SigTitle:(—a✓/'0//027 Date: FDEPARTMENT USE ONLY a Application Accepted by �,E( ��QA"A- IAti..L Date — ` Area 17, Pit or Grout Inspection by Data Final Inspection by Date Additional Comments: Applicant - Return all copies to: 8m Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 EN 324IaEV. v e m Err ta_M FEE NFO gMOUNT DUE AMOUNT REMITTED CK CASN RECEIVED BY DI DATE PERMIT NO. �l d,� m ►� i 91 CL ��