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APPLICATION FOR PERMIT ;, S, s SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX2009, STOCKTON, CA 95201. 6 pr (209) 468-3447PMM- JUS iL (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 eouplienee with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ,2-Za CityS s G A c'Ytf GA —Al Lot Size/Acreage 74X Job Address Owner's Name EA WA D '�� Address Hyo Phone 3�333G Contractor F� --- Addressrvice irD �E3 ,,'7` License No, S<?SYS—Phone s 3771 11 1—rice well I We TYPE Of WELL/PUMP: ; NEW WELL ❑ WELL REPLACEMENT f7 DESTRUCTION ❑ Out Monitoring well a - ' 'x '�._.- : SYSTEM'RE ❑.-�..,--. —OTHER ❑ PUMP INSTALLATION ❑T WER LINES DISPOSAL FLO. PROP, LINE DISTANCE TO NEAREST: SEPTIC TANK-- OTHER WELL PlTSlSUNAPS FOUNDATION _._..�_� AG CULTU ELL INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS Dia of Well Casing f-1 Industrial n Bottom ❑ Man ^a T Dia. of Well Excavation m ❑ Ops "'- acy -e of Casing Specifications Y Specifications U Domestic/Private ❑ Gravel Pack Depth Grout Seal Type of Grout ❑ Public'--' a E I�1 Other ❑ Delta G Irrigation a_ w Approx. pth El Eastern Surface Seal installed by H.P. State Work Done Repair Work Done, L] Type of Pu p �-Y-- ' Sealing Material i Depth Well Destruction O Well Diameter Filler Material i Depth _ Depth - rmitted if ublic sewer is (� TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION Ll DESTRUCTION aNailabQerw thin 200 leat.l p Installation will serve: Residence'—.... Commercial Other�— J Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: No.-.Compartments SEPTIC TANK. ❑ -Type/Mfg'^"� Capacity Method of Disposal PKG, TREATMENT PLT. ❑ Distance to nearest: Well Foundation. ,.Property Line — LEACHING LINE ❑ No. &Lenon: lines Total length/sire FILTER BED ❑ Distance to'naarest: Well Foundation______-:_-Properly-Line--;-- SEEPAGE PITS 11 Depth Sire Number SUMPS CI Distance to nearest: Well Foundation Property Line --- DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county-ordinances, stale laws, and ' rules and regulation$of the San Joaquin County llowing: "I certify that in the performance of the work for which this permit is issued, 1 shall not Home owner or licensed agent's signature certifies the to r pensation law$of California." Contracior's hiring or sub contracting signature employ any person in such manner as to become subject 10 workman's com 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 eompensa• tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side 01, Date: Signed Title: FOR EPARTMENT USE ONLY 1 1 � Date Application Accepted by i Date i Date Final Inspection by Pit or Grout Inspection by Additional Comments: h%^ Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESt` + ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTOl 05201 FEE AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT NO. INFO '�!„0 + EH 13•24 INt;V.I/nS1 i �RI EH 741.26