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r~ <br /> f x APPLICATION FOR PERMIT <br /> I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> t PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> i` <br /> (Complete in Triplicate) <br /> I 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 City Lot Size/Acreage <br /> ,... �} <br /> Owner's Name er Address �L Phone <br /> ., License No. Phone <br /> Contractor ddress <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL RE ACEMENT C DESTRUCTION ❑ Out of Setice Well1-1 ❑ <br /> F PUMP INSTALLATION ❑ S TEM REPAIR 0 OTHER ❑ Monitoring Well C� y <br /> DISTANCE TO NEAREST: SEPTIC TANK '� SEWE LIN DISPOSAL FLD. F PROP`UL E <br /> FOUNDATION:. "z a AGRIC RE WELL OTHER WELL PITS/SUMPS t" <br /> INTENDED USE TYPE OF WELL r PROBLEM AR CONSTRUCTION SPECIFICATIONS I <br /> n Industrial ❑ Open Bottom ❑ Mantec *;Dial of Well Excavation Dia. of Well Casing <br /> *;� t.l.Domestic/Private ❑ Gravel Pack ❑.Trac }. Type of Casing Specifications <br /> i'l Public 1-1Othert n D a -Depth of Grout Seal Type of Grout <br /> ` 5.i 1.Irrigation _r I € r.Approx. Depth I I astern Surface Seat Installed by <br /> U Y Type of Pump H.P. �. State.Work Done <br /> Repair Work Done <br /> l ; <br /> SealirA Material.&`Depth L t <br /> Well Destruction ❑ Well Diameter <br /> Depth <br /> t. 'Filler t i- 1 1 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIRIADDIMON�ETRUCTION l I INo septic system permitted if public sewer is <br /> ail.b wilhi 200 fInstallation will serve: Residence Commercial ' ther . ! <br /> Number of living units: Number of bedrooms ! <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. ❑ t 1 `` I Method of Disposal <br /> t Ig !-�- . -�,,,� � <br /> t Distance to nearest: Well.v oundation S ' �X; roperty Line_1 13 %JI <br /> JV <br /> h LEACHING LINE Cl No. & Length of iiries Total length/size <br /> i FILTER BED C] Distance to nearest: Well Foundation' Property Line <br /> j 17- <br /> t SEEPAGE PITS i I Depth e } t- - umber <br /> SUMPS % LI Distance to nearest: foundation Property Line <br /> DISPOSAL PONDS ❑ k <br /> I hereby certify that I have prepared this applica on and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> pl <br /> rules and regulations of the San Joaquin County., .• `X <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which tis permit is issued, I shall not <br /> j 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 /> h <br /> r cenifies the fohowirig: 'A 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."i x ' <br /> The applican must call f 'all rrequi ed inspections. Complete drawing on <br /> -- <br /> Q-�i�Y_ ►-.[�� __ Date: <br /> Signed <br /> F. R DEPARTMENT USE ONLY �f <br /> Application Accepted t]y 1 % Date Area <br /> 17 <br /> f Pit or Grout Inspection by �' Date. Final Inspection by Date <br /> E Additional Comments:-L44 w I2,rI `' ` o� -y <br /> Applicant - Return all copies to: San Joaquin County Public He lth <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> t FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH — <br /> . n.K 2J.ry9,v.*rv4.5,_.7._. ...�•� -�-�' E �` � �• + j-� b - ]o��gj .`` �° <br />