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APPLICATION FOR PERMIT 1 • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION f 1601 E. HAZELTON AVE. , PHONE C2095201-3420 P O BOX 2009; STOCKTON, � ESPIRES T YR9R_FROM DATE ISSSJ� (Complete 1n Triplicate) Application is hereby made.to San Joaquin County for a permit to construct sad/or 62 and the work herein described. This application is made in capliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations oS Ban Services- Joaquin County Public Health Services. r 7d?/ City Lot Site/Acreage �.---- Job Address T--- 1 �_ ___ Address Phone Owners Name _^—' --��' C r Contractor Address .. 6 - License No - Phone NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Oat of Service Well ,Ll D TYPE OFA MP" SYSTEM REPAtR ❑ OTHER ❑' MonStor3ng Well PUMP INSTA2LATIONtD � DISPOSAL FLD. PROP. LINE _— SEWER LINES P17S/SUMPS DISTANCE 70 NEAREST: SEPTIC TANK^- OTHER WELL ----- ° 1I,"AGRICULTURE WELL FOUNDATION INTENDED US£ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Open,Bottom„_.4 Mantapa� _,Dia..of Well Excavation. x ❑ Industrial ❑Tracy Type of Casing r Stxcihca[ans „ D Domestic/Private ❑ Growl Pack Depth of Grout Seal t Type of Grout_�--�-- I'I Public fa Other D Delta ;App(ox. Depth 1 I Eastern Surface Seal Installed by l i Initiation — ---.-�^—""� State Work Dona H.P. Depth Repair Work Done CO Type of Pump Materiali � Seating Well Destruction ❑ Well Dismriter/t ' Filler Materiel 6&Depth r pePth • _ -_ rTION avaStable within 200 feet.) TYPE OF SEPTIC WORK: NEW INS7ALLATIO REPAI;lADDITION 1 I DESTRUCTION I I Wo septic system parmmed it public sewer n tnst getion will serve: Red nus-�Commercial_ Wither t Numtier'Of1Wfooi 3 f A _ Number of living units: �. } ��, Water table depth Character of nor to a depth of 3 feat: �! .nd Capacity-J + 'No. Compaq rtments 2" SEPTIC TANK. fiZ Type/Mfg ----r---F .. } Method of Diaposel " t / PKG. TREATMENT PLT.❑ C � �� C� / ,meq Foundation Property Line Distance tDnearest: j}Weil`-mar--- { Total length/size LEACHING LINE �. N°- 8 Length of hues "'---- /y Property Lina ❑ Distance to nearest; r Wall Foundation A r j FILTER BED � . �I Depth t A!• L Size Number i SEEPAGE PITS Foundation Property Line — ! SUMPS LI Distance to nearest: Wali�QO_ DISPOSAL PONDS ❑ E F 1 hereby certify that I have prepared tfiis'�pplicatiori.-and that Its work and will be done in accordance with San Joaquin county ordinances, state I shall not rules and regulations of the San Joaquin County" w 1 certify that in the performance of the work for Which this permit is issued. Home ownesub-contracting signature r or licensed agent's signature laertifb4 the Lobo. g: " employ any the Drown in sulc` IN manner as n o bac A�m ble*t-lb work for whichthls perm tion tis issued,s Of floshall employ Personsraubjs�t to wo+kman'wmPensa- ng:111 the Pa tion.laws of California." �— The applicant mw call all r�QU ed i petitions.Complete drawing on re�v+eprse side. pate: - O / Title: / qsw ALJ Signed FPARTMENT USE ONLY �7 Date �1 ^011 -91� Area/--- Application Accepted byQ..4 ��z ems— Date Pit or Grout Inspection by Data Final inspection by Am Additional Comments: A Applicant - Return all copies to: Ban Joaquin County PublicHealth Services Services, Enviroaments2-atal Health Permit/ 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 CK RECEIVED By DATE PERMIT NO. [FEE AMOUNT DUE AMOUNT REMITTED CASH INF 6D i 20 6 47-� go-i . EH 1421{REV.1 r x e+ EH 14211