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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT 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 the Rules and Regulations of San Joaquin County Public Health Services. Job Address �C1`33 �ifr�T `0-eo rrs y e-e City Lot Size/Acreage Owner's Name .l%ig' !_fC Address Phone Contractor &21r,2 rS`X Address JD' /�!1[ /Z=F`� License No., �.z J Phone -7 " f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER Monitoring Well C7 3 3'014 sic ei vis DISTANCE TO NEAREST. SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLVACONSTRUCT)dTN SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manxcavation Dia. of Well Casing 1-1 Domestic/Private ❑ Gravel Pack n Tracing_ Specifications f I Public 1-1 Other n Deltout Seal Type of Grout I I Irrigation —Approx. Depth 11 Eastl Installed by Repair Work Done U Type of Pump . . State Work Done Wog Destruction ❑ Well Diameter Matlfi&l i Depth Depth Tiller Material i Depth 0 TYPE OF SEPTIC WORK: NEW INSTALLATION I I RE IR/ADDITION I I DESTRUCTION I I lNo septic system permitted if public sewor is available within 200 feet.) {-y-` Installation will serve: Residence_ Commercial that Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. O Typo/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well oundation Property Line LEACHING LINE Cl No. a Length of lines Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Property Line SEEPAGE PITS i ) Depth .Size Number SUMPS L1 Distance to nearest: Well Foundation . .., .._w, Property Line DISPOSAL PONDS ❑ —7�F 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 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 foNowing: "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 mull 11 for all requir ins . tions. Complete drawing on reverse side. Signed Title: Date: _��E �`�CP Z-- FOR DEPARTMENT USE ONLY 7 S Application Accepted by Date Z �" Area Ph or Grout Inspection by Date Final Inpction by Date Additional Comments: Applicant - Return all copies to: S Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 IN K I FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED(!Y DATE PERMIT AFD. r • EN13.24(IEV.1/R 5) �=' ' Z,�j ,Z ` Z EH 141-M