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tq ka at 44 APPLICATION FOR PERMIT �� 7a ��I' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES } SZ J)6 ��,( j ENVIRONMENTAL HEALTH DIVISION U 4445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT R3MTPRR i YLAEM FR N DATE 13S (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. J Job Address -___L X 1 7 o � e J^ r /g/Ogil City 70t= C Lot Size/Acreage l Owner's Names[61 Addressv t- Phone ff f Contractor .�L °�Address /^ License No.��Phone TYPE OF WELL/PUMP: NEW WELL WE REPLACEMENT C7 y k DESTRUCTION ❑ Out of Service t1e11 ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ !Monitoring Yell DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. pAOP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS IN ENDED USE PE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT O fr dustriai pen Bottom ❑ nteca Dia. of Well Excavatio Dia. of Well Casi fes. D0 hli 'ticlPrivate Gravel Pack racy Type of Casing_ 1_ v` t'I ublic C3 Other s1: �^ Specifications d fl Delta Depth of Grout Seal '_ Type of Grout I I Irrigation q ~' s -- pprox. Depth I I Eastern Surface Soul Installed by 'P t!` Repair Work Done Ll Type of Pump H p Well Destruction ❑ Well Diameter Sealing Material i Depth State Work Done Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDtTION i I DESTRUCTION I I (No septic system permitted if public sewer is Residence Installation will serve.- Commercial Other available within 200 feet.) Number of living units: Number of bedrooms Y Character of$oil to a depth of 3 fast. Water table depth SEPTIC TANK. ❑ Type/Mfg I PKG. TREATMENT PLT. ❑ Capacity No. Compartments Method of Disposal Distance to nearest Well � Foundation Property Lina LEACHING LINE ❑ No. S Length of lines FILTER BEDTotal length/sire ❑ Distance to nearest: Wall Foundation ' Property Line SEEPAGE PITS 11 Depth, Sire SUMPS Number t LI Distance to nearest: Well Foundation. DISPOSAL PONDS ❑ � ------- Property Line I hereby certify that l 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 shell 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 certtftn 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 Calif : The applies call f fired inctions. Complete drawing on r v se speside. Signed Tide: Date: _ENT USE ONLY Application Accepted by bate— `� c Area ` Grout spection by �•.: Data — �Ejnat Inspection by Date 6 CeQ 1,� Additional Comments: 44 Applicant - Ret n all•copies San Joaquin County Public Health Ser ices k j Environmental Health Permit/Services 11 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFOL;;NT DUE AMOUNT REMITTED CK / Y GASH RECEIVEp BY DATE PERMIT•NO. EH 111 iREV.irsSi N /'t 1 �jq� np i �EH /r V Q i/V I