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APPLICATION FOR PERMIT V SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 4� ENVIRONMENTAL HEALTH DIVISION �y 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 - PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .(Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ,,,��p ) i Job Address y�M 7.r�.— /tel• 1Q f?14yL\� /S n City S�/l wLo�t size/Acreage Owner's NameR6&4AI 2!! /7fX^5 Ah' P,ress� /a2O �• Z4/4*/J 4JPhone _.,. Contractor L G Address SAMd, License No. Phone .� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Monitoring We'll ❑ll PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ U �^ DISTANCE TO NEAREST: SEPTIC TANK SEWCR'UI ES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE`6TVVMt-,F,;,,,fAOSLEM AREA. CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑'URNLilt°U Dia. of Well Excavation�_ Dia. of Well Casing - A ❑ Domestic/Private :1 \❑ Tracy Typp-of Casing Specifications \l' Pl Public fa Other ^ (l-0A**__., R Ih of Grout Seal __ Type of Grout 1 I Irrigation _.Approx. Depth I I Eastern Surface SeulIns ft='�Iiy- Repair Work Done 0 Type of Pump H. State Work Done Well Destruction ❑ Well Diameter Se Material i Depth r Depth Pi#l£r Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR IADDITIOKKf I DESTRUCTION I I (No septic system permitted if public sewer is / available within 200 Ieet.1 Installation will some: Residence. -commercial-/ Other . Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKC. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well �� Foundation --F0tt al =— Property Line�_ LEACHING LINE D/ No. g Length of lines Tal length/size 1 FILTER BED ❑ Distance to nearest: Well. ,00 Foundation I S '- Property Line _- SEEPAGE PITS 11 Depth - Size Number ,., SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 1 hereby conity 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 r_ 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 pars n in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the foll i g: "1 if t he performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion Iowa f Ca to n1.." The appli t us call or all F i d i s coons. Complete drawing o averse sid Signed I I Title: We: Date: i FOR NIT USE ONLY Application Accepted by Data PT( '1.' J,� Area Pit or Grout Inspection by Date Final Inspection by Date � O 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 CASH CK I RECEIVED BY DATE PERMIT NO. . EM 1124(A".rix el EM 1428 ,0 l l CJv