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APPLICATION FOR PERK[I T d SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ` 445 N SAN JOAQUIN, PHONE (209)468-3420 L f 1*10 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I YEAR FROM DATE ISSUED € (Complete in Triplicate) Application is hereby made to Sati(osquin County for a permit to construct and/or instal the work herein described. This application is made in compliancelwith San Joaquin county Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Servi / ces. )(Job Address _l ,,e1 p�__ City Lot Size/Acreages Owner's Name Address 13a Phone -ela '�1� /1<4niractor 61p�g ___ � Address t # License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM RE IR ❑ OTHER ❑ litonitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK EWER LINES DISPOSAL FLD. r PROP. LINE 1 FOUNDATION A&iQCULTWt1rWELL :OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WE PROBLEM CONSTRUCTION SPECthCAT10NS r Ll Industrial ❑ Open So m 0 eca Die. I-Well Excavatibn Dia. of Well Casing 0 Domestic/Private C] Gravel ack Tracy Type of Casing- -' Specifications Il Public Ia Ot r # n Delta Depth of Grout Seal Type of Grout I I irrigation _iAp x. Depth I I Eastern Surface Seal installed by �\ Repair Work Done U Type of Pump' H.P. State Work Done v`� Well Destruction ❑ Well Diameter Sealing Material i Depth Depth I I filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is vailabla within 200 feet.) Installation will serve: Residents_ Commercial__,_ Other Number of living units: Number of bedrooms ' Character of soH to a depth of 3 feet: , Water table depth. SEPTIC TANK. ❑ Type/Mfg Capacity No, Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. b Length of lines Total length/size FILTER BED ❑ Distance toj nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundstion 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 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 following:"1 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 applican must call f r all r ins tions. Complete drawing on reverse side. 9 Signed X Title: 0:6 �. Date: FOR DEPARTMENT USE ONLY Application Accepted by _ _. Date �l f Area Lf/ Pit or Grout Inspection by Date Final Inspection by Date �f Additional Comments: Li Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE CK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. r EH t}2,@ IREv-1- p 7 'eP v N t1•Ie � r