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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 O 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 with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. -1 (fir �T. Lot Size/Acre e Z. Job Address 2 < ( �.� �ca�K� �� City Size/Acreage SGS Owner's Name Address Phone g t Contractor - %Z /dress .S License No.Yli� Phone TYPE OF WELL/PUMP: iv NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SE ER L ES DISPOSAL FLD. PROP. LINE _ FOUNDATION AG ICU TURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ OPen Bottom ❑ Maniac Dia. of Well Excavation Dia. of Well Casing [I Domestic/Private EI Gravel Pack ❑ Tracy Type of Casing Specifications I Public Cl Other Ll_Del[ Depth of Grout Seal Type of Grout I I luigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. Slate Work Done _ Well Destruction ❑ Well Diameter Sealing Material L Depth Depth Filler Material i epth TYPE OF SEPTIC WORK' NEW INSTALLATION I I REPAIR/ADDITION 1 I ESTRUCTION 1 1 JNo se Ic system permitted if public sewer is ,� l vaifa within 21'x1 feet.) Installation will serve: Residence J Commercial /1�er � /� nl Number of living units: Number of bedrooms llY Character of soil to a depth of 3 feel: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity U No. Compartments PKG. TREATMENT PLT. ❑ / ,. Method of Disposal (JJ Distance to nearest: Well _1�!1C Foundation /_�,L�'iA/��t- Property line LEACHING LINE L1No. 6 Length of lines - Total length/size '- FILTER BED D Distance to nearest: Well `a Foundation 6)0 Property Line 0 fr � SEEPAGE PITS If Depth Sire Number F SUMPS LI Distance to nearest: Well FoundationT(7 Property Line C DISPOSAL PONDS ❑ D I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, slate laws, and rules and regulations of the San Joaquin County - - Home owner or licensed agent's signature cenifies the fohowing-`Ycwtify Thatin theperformanceof the work-!or which-this pwrMiTis Issued,-1-Willi employ any person in such manner as to become subject to workmen'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, I shall employ persons subject to workman's compensa- tion laws of California." The applican ust caller-ag require inspections. Complete drawing on reverse side. Signed Title: Date: Date: /5 R DEPARTMENT USE ONLY Application Accepted by 1. �-w� �3yy,nonQ Date '-1 �- Area / Pit or Grout Inspection by Date Final Inspection by - Date 6 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permlt/Services 1601 E. Hazelton Ave., P 0 Box 2009. Stockton, CA 95201 FEE INFO MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO, . EH 1724IREV..ix51O,'O�c �+-} V S Co -Q-90 7. y q EH-.41.26 U y 1