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APPLICATION FOR PERMIT � <br /> x <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ovz <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 Go�vN�P_ �gYEtii�� .Su&D <br /> nI:�T'r Ts%PIRES 1 YEAR DATE ISSUE <br /> 71 3J q/6 I;complete in Triplicate) <br /> k <br /> Application is hereby mde,to Sap Joaquin County for a permit to construct and/or install the work herein described. This j <br /> application is made in coaopliance with San Joaquin County Ordinance No, 549 and 1�and the Rules and Regulations of San $ <br /> Joaquin County Public Health Services.�N rS 076- 330 — Al 17-0., I <br /> City Lot Size/Acreage <br /> Job Address i <br /> 723- <br /> Owner's Nam <br /> a$LtS gL �o>ChW Address OY &—"'014gf- hone �Z <br /> ` Address � � E� my�'�e 57"z_License No,57Z266 Phone g;--/3 <br /> t <br /> Contractor <br /> ce e <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERIto�L°g_]rlell-F� r5 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL,FLD. --- °n` <br /> FOUNDATION AGRICULTURE WELL OTHER WELL r*ISI <br /> r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 6 <br /> Industrial ❑ Open Bottom ❑ Manface is. of Well Excavation <br /> fl <br /> U Domestic/Private Ci Gravel Pack ❑ Tracy Type of CasingactttO"s <br /> f�t•- <br /> ❑ Public [1 Other ❑ Delta Depth of Grout Seal �t It <br /> 0 Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done c <br /> Will Destruction 0 Weil Diameter <br /> Sealing Material i Depth <br /> Depth Filler Material 4 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L] REPAIR/ADDITION LT DESTRUCTION D (No septic system <br /> m rented if public sewer is <br /> available installation will serve: Residence— Commercial Other <br /> Number of living units: Number of bedrooms - <br /> Character of coil to a depth of 3 feet: Water labia depth a- <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ri- <br /> PKG. TREATMENT PLT, C1 Method of Disposal n <br /> Distance to nearest: Well Foundation Property Line e <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line O <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and nd that the work will be done in acs <br /> ordance with San Joaquin county ordinances, state laws, ands <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 shell not , <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature.,,�ttt���111 <br /> cenifiea 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 compenca <br /> tion laws of California.' <br /> x The applicant ffKt call for a uired inspections, Complete drawing on reverse side. <br /> .v.6 D <br /> . 6Fa[7L-a�7sr ate: '5 -/5-9 — <br /> Signed Title- { <br /> f% RDMENT USE ONLY _� <br /> Application Accepted by Date / Area <br /> Pit or Grout Inspection by Date Final Inspection by w Date t <br /> Additional Comments: �� `` `t'`a__5A - <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON. CA 95241 <br /> kFEE AMOUNT OUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. <br /> INFO <br /> . FH 1]•741REV. ei <br /> EH <br /> i <br />