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APPLICATION FOR PERMIT ' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' ICY M ENT, i ENVIRONMENTAL HEALTH DIVISION RECEIVED 1601 E. HAZEL,TON AVE. , PHONE (20g)468-3420 P O BOX 2009, STOCKTON, CA 95201. � 2 PF-RMIT EMRES 1 YEAR FROM DATE ISSUED ._..._- lJ (Complete in Triplicate) FNVIKUIWENTAL MIArM Application is hereby trade to San Joaquin Count for-a k herei desc CC DA Y q y permit to construct and/or install the work herei descrlbSd. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1662 ¢nd the Rules and Regulations of San I Joaquin County Public Health Services. �� I s Job Address ,2-3 N �O��A City's ��A--, Lot Size/Acreage its S7, Owner's Name - _ -- -- - _ - A dres�/ / r�� I' S' Phone Contractor cs�cc �o-ti_-£xdais �.� Address 2� Ie License No. TYPE OF WELL/PUMP: NEW WELLS WELL REPLACEMENT [-1 DESTRUCTION Q Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ `r �°rtiRrelll J DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES BOO DISPOSAL FLD. PROP. LINES j FOUNDATION !Dd AGRICULTURE WELL OTHER WELL PITS/SUMPS N INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIF,ICATtONS n Industrial ❑ Open Bottom ❑ Mant��'Ype iaof Weil Excavation Dia. of Wail Casing Cl Domestic/Private Gravel Pack ❑ Tra of Casing f ✓� Specifications Il Public I'l Other D Depth of Grout Seal G Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed Repair Work Done U Type of Pump H.P. State Work Done - Well Destruction ❑ Well Diameter Sealing Material Its Depth Cl-n; ®Y17 Filler Material' A De th C ti Depth p .�S 8 /`0 3��- TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIRIADDITION I I ' DESTRUCT10N4 I iNo septic system permitted if public sewer is available within 200 feet.) :Installation will serve: Residence—. Commercial_ Other 'Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth r SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED C) Distance to nearest: Well Foundation Property Line I SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby candy 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 I sr, . " 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 I certifies the following: "i certify that in the performance of the work for which this permit is issued,-1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: T�O., ?i„j)322 Date FOR DEPARTMENT USE ONLY Application Accepted by Dat Area Pit or Grout Inspection by Date Final Inspection by Date -qv Additional Comments: Applicant - Return.all copies to: San Joaquin County Public Health Services, Environmental Health'Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED A5W RECEIVED 9Y DATE PERMIT'NO. . CH d3-24 IREY.t/e Sr