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APPLICATION FOR, PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95207. <br /> 1 EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application Is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address ityslsOi�ot Size/Acreage <br /> [rte =slw�o _57v4� e F'Ri�57 �°'6o)C 56237 I,S�E�.�� <br /> ((n�ff S S e 6hone <br /> Owner's NarnA©!: D w A R Ad ress <br /> �- <br /> ��ttoo�' Tj D <br /> Contractor Xddress �._?q��'C�� >?R fV- c nse No.J�ll Pf�ont <br /> i <br /> TYPE OF WELL/PUMP: . EW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ Out of Service well. ❑ <br /> PUMP INSTAL ION ❑ SYSTEM REPAIR ID OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM A CONST CIFICATIONS <br /> n Industrial ❑ Open Bottom C7 Mania is. of Well Excavation Dia. of Well Casing <br /> E7 Domestic/Private ❑ Gravel Pack Tracy Type Casing Specifications e <br /> i'l Public [ er i1 Delta Depth of ut Seal Type of Grout <br /> i I Irrigation _Approx. Depth I I Eastern Surface Seal Ins ed by <br /> Repair ork Done U Type of Pump H.P. tate Work Done C Well Destruction O Welt Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I } DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) n /1 <br /> Installation will serve: Residence_ Commercial_ Other V <br /> Number of living units: Number of bedrooms d <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. 0 _ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well fi Foundation Property Line <br /> SEEPAGE PITS l I Depth Sire Number <br /> SUMPS LI Distance to nearest: Well € Foundation Property-Line <br /> DISPOSAL PONDS ❑ /1# <br /> 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 / <br /> rules and regulations of the San Joaquin County <br /> 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 <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> 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- <br /> tion laws of California." <br /> The applicant ust call for all required inspections. Complete drawing on reverse side. ar <br /> Signed %__ � .1 Pm Title: Date: �_-/2_e2 A;�!",) <br /> 6(a F DEPARTMENT USE ONLY <br /> y <br /> Application Accepted by k ate —� `� Area d <br /> Pit or Grout inspection k . Date Final Ins p ction by Dae c- C <br /> Additional Comments: Lr 6S'O& <br /> Applicant w Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> P 1601 E. Hazelton Ave., P O 2009, Stockton, CA 95201 y <br /> FEEOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> IN A (� e� <br /> EH 13.24 IREV,t i h SI X — /0 <br /> C V �V G <br />