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A-11PLICATION FOR PERE IT SAN JOAQUIN COUNTY PUBLIC H.EALTR SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTOIN, CA 95201 2 0 9) 46 S--54.4-' 3��>'/,' P IT EXPIRES i YEAR FROG DP E ISS[TISP _ (Complete is Triplicate) Application is hereby sade,to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with Sar. Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. d� Y � / Job Address !� — �C^ V Cl Cit Lot Size/Acreage C _ �C'`,% r"]L_L 7 � Owner's Name (I C�__.�- �-��=�- Address ��-��-�.� �, Phone ContractorAddress License No. Phone ' TYPE OF W PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out QS-Service Well ❑ P LATION O SYSTEM REPAIR C] OTHE Monitoring Well O DISTANCE TO NEAREST. SEPTIC TANK EWER LINES DISPOSAL PROP. LINE FOUNDATION AGRIC WELL R WELL PITS/SUMPS Si INTENDED USE TYPE OF WELL PROBLEM AREA riU SPECIFICATIONS ) (_� Industrial ❑ Open Bottom ❑ M Dia. of Well Excavatio Dia. of Well Casing L) Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications �• _ 1-1 P�.blic I 1 ❑ Delta Depth of Grout Seal Typo of Grout G Irrioation Approx. Depth C3 Eastern Surface Seal Installed by Aspair one ❑ Type of Pump N.P. State Work Done _ We Destruction ❑ Well Diameter Sealing Material & Depth r Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION Ll DESTRUCTION CI (No septic system permitted if public sewer is available within 200 feet.) _ Installation will serve: Residence ,X, Commercial_ Othor Number of living units: / Number of bed ooms - Character of &oil to a depth of 3 feet: k 17 - Water table depth SEPTIC TANK ❑ Type/Mfg Capacity— No. Compartments ' PKG. TREATMENT PLT. Q // Method of DDi Rossi Distance to nearest: Well/ oundation F� Property Line we d. LEACHING LINE IN No. & Length of lines qXq — Tota,length/size FILTER BED 0 Distance to nearest: Well Foundation� Property Line d f SEEPAGE PITS I0,"'Depth Size 4'- Nyimbar .� SUMPS LI Distance to nearest: Wel at c r Foundation� Property Line - _ C DISPOSAL PONDS ❑ 5'2� I 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: "I certify that in the per';ormance of the work for which this permit is issued, I shall not employ any person in such manner 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all a Ire spections. Complete drawing on reverse side. Signed - Title: �t f�E:S� Date: — ' a_ , O EPARTMENT USE ONLY 1Application Acespted by Data Aroco � or Grout Inspection by� � ��Date V-2 Z Final Inspection by - Date� / Additional Comments: LL _ Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 85201 ♦FEE I � INFO OUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. -- EI H 173 24 1t+EV.r i w si j r Q Cl ;C� ! I 1�t o� q k(—um[[