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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIROMG NTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 Cb%4 r PERMIT EXP I RPS 1 YEAR FR-M- D TE I NCO C' (Complete in Triplicate) _ ►�,�� i Application is hereby made to San Joaquin County for aU" the vork application in made in coetpliance frith San Joaquin County rmit OrdinancenNo. 549 andstruct and/o18F2eand the Rules andeRe described. This k Joaquin County Public Health Services. "tions of San k t Job Address ZO Z:5 z{ --, Z-1-Ir- City S Z;C'1 J Lot Si ze/Acreage �Zca a e7 y^ Owner's Name Lf-e s Address T Contractor�L-&' is _E-E Address License No. Phone TYPE OF WELL/ NEW WELL ❑ WELL REPLACEMENT {7 • DESTRUCTJON-JR"t)ut of Service dell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES OSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WEL - OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM ARE NSTRUCTlON SPECIFICATIONS n Industrial 0 Open Bottom. ❑ Ma Dia. of Well ExcavationDia \ 11 Domestic/Private ❑ Gravel Pack racy . of Well Casing — Type of Casing- V)I I Public [1 Other fl Delta Depth of Grout Seal I I IrrigationType of Grout pro>,. Depth I ! Eastern Surface Seat Installed by Repair Work Done ype of Pump H.P. State Work Done_ Well Destruct' ❑ Waft Diameter •Sealing Material 1k Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION X, INo septic system permitted if public sewer is - available within 200 feet.l Installation Residence_ Commercial, Other Number of living units: Number of bedrooms 7- Character of Boit to a depth of 3 fee. SEPTIC TANK. star table depth ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: -Well I tion Property Line LEACHING LINE ❑ No. A Length of Ii FILTER SED. Tot th/six's D Distanc rest:- ` Wall - Foundation Props no d 4 SEEPAGE PITS 11 Depth Siva ' SUMPSNumber Cl Distance to nearest: Wall Foundation DISPO PONDS p ------ Property Lina y 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 f employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifiers the fCNowin is ,, certify that in the performance of the worst for which this permit is issued, f shall employ persons subject to workman's compensa- tion laws of California." The a ant must call fol all qDquired inapectione, Complete drawing on reverse side. Sig JP%V1.0o Title: Date: 60-- Z7�--Z- FOR DEPARTMENT USE ONLY LL Application Accepted by r Date�.0 a1=9�-- lJ Z Area Pit of Grout Inspection by Date Final Inspection by / , Date L Additional Comrtlanta: e-e•� G[.ee,.r,. t'�-�••ee Applicant - Return all copies to; San Joaquin County Public Health Services Environmental Health Permit/Services F 445- N San Joaquin, P O Box 2009, Stkn, OA 95201 FEE AM OUNT DUE AMOUNT REMITTED K INFO RECEIVED 8Y DATE 14.20 PERMIT•NO. s Eft IREV.tical �5D 7 , � / Gw� =EH 11-� f p