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APPLICATION FOR PERMIT n <br /> s� <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ft�v <br /> � <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468--3447 R <br /> (Complete in Triplicate) <br /> Application is hereby made to San J0e4uin 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 Ban <br /> Joaquin County Public Health SeTvieAs. <br /> 11�,Q�C��GQGC��(J Cit Lot Size/Acreage <br /> tob Address AddressPhoneName <br /> ss __L-icense-No.- —Phone <br /> torF W LLlPUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION ❑ Out of Service Nell Cl <br /> PU P INSTALLATION 0 SYSTEM REPAIR 0 <br /> pTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK —,,.SEWER LINES ��-pISPOSA�FLDs-- P. LINE <br /> -FOUNDATION AGRICULTURE WELL ELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA UCTION SPECIFICATIONS Dia. of Well Casing <br /> I f7 industrial ❑ Open Bottom ❑ M �– Dia. of Well Excavation <br /> Type of Casing Specifications <br /> -- <br /> U Domestic/Private ❑ Grave! Pack C] Tracy . .,' Yp Type of Grout <br /> Public I:1 ❑ Delta Depth of Grout Seal <br /> G tfrigalion _Approx. Depth ❑ Eastern Surface Sidi Installed by <br /> Rep ' ork Done U Type of Pump H.P. State Work Done_ <br /> Sealing Material & Depth <br /> Well Destruction ❑ Well Diameter Filler Material 4 Depth <br /> Depth <br /> TYPE Of SEPTIC WORK; NEW INSTIL_ TION❑ REPAIRIADDITION LT DESTRUCTION G (Nailabpelwnhin m isolated it public sewer is <br /> Installation will serve: Residence_ Commercial 0`ther <br /> Number of living units: Number of bedrooms <br /> Water fable depth <br /> Character of soil to a depth of 3 feet: <br /> r SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 '.- Method of Disposal <br /> Distance to nearest: Well Foundation Property Lina <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> f FILTER BED 1:1 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Lina <br /> DISPOSAL PONDS 0 <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, 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 sub-Contracting 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 /> Xha applicant must call for all required ins ctions. Complete drawing on reverse side.igned K �/�� _ Title: nate: <br /> F EPARTMENT USE ONLY <br /> � Date Area <br /> Application Accepted byA / ) <br /> i 21 <br /> Date Final Inspection by Date <br /> I Pit or Grout Inspection by <br /> Additional Comments: <br /> Applicant Return all copies to: VICES <br /> EN JOAQUIN COUNTY PUBLIC HEALTH <br /> IRONMENTALHEALTHDIVISIONPERMIT/ SERVICES .fes• <br /> I 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> FEE C RECEIVED BY DATE r EftM17 NO. <br /> INF OUNT DUE AMOUNT REAki�1TEt) CASH 4 �y /� <br /> . EH 13.24Mev.rVn5i `?0�a3 <br /> EH;�•ie <br />