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I E APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 I P 0 BOX 2009, STOCKTON, CA 95201. DgMIT ESPIRES 1 YEAR FRM DATESS [JID (Complete in Triplicate) Application is hereby made.to Sen Joaquin County for a permit to construct and/or install the vork 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. i 77 '' Job Address __e SOD _ City Lot Size/Acreage ! � ' Owner's Name �k'�Ad / /J �!Tr'A Address SSC Phone '41 Contfactor F�YP E, L[JOO___Address` e!�• License No: l4 Phone S 9 j TYPE OF WELL/PUMP: "- y iVEW WELL © �WELt REPLACEMENT ( 1 -DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ `07HER p' Monitoring Well '�� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION GR ICU LTURE L OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WZEasle,rn E C4N_STRLfCTION_SPECIFICATIONS F-) industrial !� Open BottDia. of Well Excavation Dia. of Well Casing Ll Domestic/Private ❑ Gravel PacType of Casing_._. Specifications I'1 Public 1-1 OtherDepth of Grout Seal Type of Grout I I Irrigation .� Approx. urface Sedl installed by Repair Work Done 0 Type of PumP. State Work Done Well Destruction ❑ We11 Diametealing Ma rial & Depth Depth ° Filler Material & Depth 1 TYPE OF SEPTIC WORK', 'NEW INSTALLATION 11; REPAIR/ADDITION DESTRUCTION I i lNo septic system permitted if public sewer is r/ P U Installation will serve: Residence 'L /Commercavailable within 200 feet.) ial ;-Other Number of living units: —L Number of bedrooms _ Character of soil to a depth of 3 feel: Water table depth SEPTIC TANK.. ❑ Type/Mfg _ f 9�L� - - Capacity--2? � No. Compartments 2— PKG. PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well ,�, Foundation Property Line 421 LEACHING LINE ❑ No. & Length of Eines Total length/size- FILTER BED Cl Distance to nearest: f Foundation Property Line '1 SEEPAGE PITS 11 Depths Sire Number SUMPS ' L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ _l I hereby certify that I have prepared this application and that the work wilt 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 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 taws of California." The applicant must cal or all required inspections. Complete drawing on reverse side. Signed X F Title: r -------- Date: 1 h FOR DEPARTMENT USE ONLY r Applicatioh'Accepted by Date '� Area ` Pit or Grout Inspection byDate Final Inspection by� Data " 1 �L1 Additional Comiiients: I Applicant - Return all copies to: Brut Joaquin County Public Health '4 Services, Environmental Health Permit/Services k I 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 s FEE AMOUNT DUE AMOUNT REMITTED I CK If RECEIVED BY DATE I PERMIT N0. IN�/,�F��O CASH 1 EH 13-24IREV.I/K5) - \ EH 14-26 k [ (�