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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468--3447 tip sD .L` O <br /> YEAR PROM DATFk J§SUED <br /> , <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> appllcation is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. 11 <br /> Job Address <br /> _�. r'nn���.lQ -_ City6�u Lot Size/Acreage <br /> 1�`n t jkamAddress <br /> �}Owner's Name 1L W Phone -v `8 <br /> E 1 <br /> ContractorOLO,7f,)Z!m ----- - Address— — —L-ivense No: --s - )Phone — -- <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION Ll Out of Service Well <br /> ! PUMP INSTALLATION ❑ SYSTEM REPAIR Cl OTHER p Monitoring well C7 <br /> kDISTANCE 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 AREA CONSTRUCTION SPECIFICATIONS 1 <br /> 1 ❑ industrial 0 Open Bottom ❑ Mariieci Dia. of Weil E:icavation Dia. of Well Casing J! <br /> i U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ' <br /> LD Public t El Other ❑ Delta_ Depth of Grout Seal_ Type of Grout— <br /> ' <br /> rout II <br /> '1J lrripation c _,Appro.. Dagth O Eastern 5uriace SeuI lnstalled by� w <br /> 'Repair Work Done 0 Type of Pump ! N.P. State Work Done _ <br /> `Wall Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth iFiller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION Cl DESTRUCTION (No septic system permitted if public sewer is <br /> ii I available within 200 feet.) \l <br /> 1 Installation will serve: Residence^ Commerciale Other r <br /> y Number of living units: Number of bedrooms <br /> i Character of.soil to a depth of 3 feet: t Water table depth \ <br /> SEPTIC.TANK: ❑ Type/Mfg Capacity No. Compartments v, <br /> PKG. TREATMENT PLT, C) Method of Disposal <br /> iDistance to nearest: Well Foundation Property Line ' + <br /> LEACHING LINE .0 No. 8 Length of lines Total length/size _ <br /> FILTER SED ❑ Distance to nearest: iWell. Foundation Property Line of <br /> SEEPAGE PITS 11 Depth lSiie Number <br /> SUMPS I Cl Distance to nearest: `Weil Foundation Property Line ; <br /> DISP08AL PONDS ❑ <br /> 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, end <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 subleot 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 o California. , ; I <br /> The ap must c 11 f �✓r 11 required inspectio omplete drawing on reverse side. µ <br /> Signed Title: Date: . l O r I <br /> 0R DEPARTMENT USE ONLY <br /> Application Accepted by Date O Area <br /> AlPit or Grout Inspection by Date Final inspection by Date <br /> Additional Comments. t ' <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN 4OAQUIN, P O BOX 2008, STOCKTON, CA 85201 <br /> + <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO, <br /> ' E„113-74InEv.I/"0i L .��c Co �L : <br />