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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED COP (Complete in Triplicate) Application is hereby made,to San Joaquin County for s permit to construct and/or install the vork herein described.kan is application in made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Reguletiona o Joaquin County Public Health Services. cc Job Address _J—o City ! Lot Size/Acreage SUS E_f rA.,7E,v2 3 - Do o Owner's Name Address ,�� pp Phone /gl s3 9f - Z Contractor � - Address 7u S � License No. Phone TYPE OF WELL/PUMP: f NEW WELL ❑ IVELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well ❑ PUMP INSTALLATION ❑ BY EM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWERINE DISPOSAL FLO. PROP. LINE FOUNDATION AGRICU E WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELLA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Type of Casing Specifications I'I Public f 1 Other Depth of Grout Seal Type of GroutI I Irrigation _Approx. DepthSurface Seal Installed byRepair Work Done U Type of Pump State Work Done_ e Well Destruction ❑ Well Diameter Seal Material a Dcpth Depthel Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is + \� available within 200^feet.l Installation will serve: Residence— Commercial Other .L // Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: f Water table depth SEPTIC TANK ❑ Type/Mfg 's` Capacity No. Compartments PKG. TREATMENT PLT. DIFMethod of Dispo I Distance to nearest: Well Nn" Foundation Property Line LEACHING LINE Cl No. b Length of lines oral length/size FILTER BED ❑ Distance to nearest: Well Foundation Props ine SEEPAGE PITS 11 Depth Sire Ngrl.r SUMPS LI Distance to neesl: Well Now. Foundation Property Line DISPOSAL PONDS ❑ 1 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: "1 certify that in the performance of the work for which this permit is issued, I shall not employ any portion in such runner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature 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 applican must call foritill require inspections. Complete drawing on reverse side. r— Signed Title: %//1'!lei Date: U—U L1 OR DEPARTMENT USE ONLY Application Accepted byCww. `•"� i Date- Area Pit or Grout Inspection by ate Final Inspection.by - Date �! aSS/!— &o/`J� Additional Comments: T��19 13 '&r,I Se�S,I /hs Applicant — Return all copies to: San Joaquin County Public Health Services, Environmental Health'Pernit/Servicer 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201CK FEE INFO MOUNT nDUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. . EH L}t41REV.r/R9 ^V� --6��D �r�10 - EH14a!