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,._ APPLICATION FOR PERUIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRQNmENTAL HEALTH DIVISION 1601 E. HAZELTON AVE., PHONE (209)46$-3420 P 0 BOX 2009, STOCKTON, CA 95201 n_ PERMIT (Complete is Triplicate) Application is hereby made •.O San Jaaquia County for a permit to Construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordlnanee Ito. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address �00- Zz /�77 Ci[ cck Lot Site/Acreage Owner's Name _WAJ..,IA /�/pU Address _ Phone � 21 AD BL uM N, . o Aq. 9�C7 Contractor L & C•Address �teRnnrE J r[. S f License No. Phone 6 ge," TYPE OF WELiIPUMP: NEW WELL ff WELL REPLACEMENT ❑ DESTRUCTION 0 Out or servce Weil 17 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Q iKell DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP,LINE FOUNDATION AGRICULTURE WELL OTHER WELL PiTSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y C1 Industrial ❑Open Bottom 0 Mamesa Dia.of Well Excavation �r Oia.of Well Carsi_n-g'r C]Domestic/Private ❑Graver Pack l7 Tracv Typo of Casing Specifications�El t Il Public 1:7 Other n Delta Depth of Grout Seal Typo of Grote I I Irrigation —Approx.Depth I I Eastern Surface Soul Installed by Repair Work Done ❑ Type of Pump H.P. State Work Dons Wait Destruction 13 Won Diameter Sealing Material r1. Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION I I =No Weis shin 200 rm tted if public sewer is ynilInstallation win serv1: Residence— Commercial— Other Number of living urns: Number of bedrooms Character of soil ri a depth of 3 feet: Water table depth SEPTIC TANK 1] Typo/Mfg CapacityNo.Compartments PKG.TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No.&Length of lines Total length/sire FILTER BED Q Distance to nearest: Wall Foundation Property.Une SEEPAGE PITS I I Depth -_Sue Number — SUMPS LI Distance to nearest: wen Foundation Property Lino DISPOSAL PONDS ❑ I hereby Certify that I haw 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 _ Homs owner or licensed agent's signature certifies the following:"f 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 booms subject to workman's compensation laws of California."Convectors hiring or sub-contracting signature certifies the following:"I cattily that in the performance of the work for which this permit is issued.I shalt employ persons subject toworkman'a compensa- tion laws of California." The apWicant must a for all r uirad inspections.Complete drawing an reverse side. Signed 1r /Mrdl _Title: Date: FOR DEPARTMEKTaSE ONLY Application.Accepted by Oats --Area Pit of Groutlnspection by Date Final Inspection by_ _ Data M Addhionll Comments: Applicant – Return all Copies tot San Joaquin Counter Public Health Services, Enrlroomntal Health Permit/Services 160: Z. Basalton Ave., P 0 Bos 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDCASH FIECEIYED By DATE PERMIT'N0. INFO - .(8!1.7,tRIV.11K I. :. . (8:1•al - - .