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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES II�� ���{ <br /> ENVIRONMENTAL HEALTH DIVISION ! (!� <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DA;IE 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 <br /> Health <br /> Services. <br /> JobAddress 2_3U L4'/ L5d y( CT _ City 5-�� �f <br /> Lot Size/Acreage Z �T <br /> Owner's Name ri < le'�l`' Address 54 A ^� Phone <br /> x Contractor �� Address f03 3 WwL f� ©4 <br /> License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION 0 Out of�S�ervice We11 ❑ <br /> PUMP INS TION ❑ SYSTEM REPAIR ❑ OTHER 0 tRlltioring Well C.3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. OP. LINE <br /> FOUNDATION ULTURE WELL OT PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA TION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Ma Dia. of xcavation Dia. of Well Casing <br /> [.1 Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications <br /> I"I Public C] Other 11 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation .. pprox. Depth ( I Eastern Surface Seal Installed by f f� <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done. V <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADOITION I 1 DESTRUCTION lNo septic system permitted if public sewer is <br /> available within 200 feet.l <br /> Installation will serve: Residence— Commercial _ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth j <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. C7 Method of Disposal <br /> Distance to nearest: Welt Foundation Property Line <br /> r <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED CI Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL 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, and <br /> rules and regulations of the San Joaquin County ` <br /> Home owner or licensed agent's signature certifies the following: "I cenity 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 /> The applicant m call for all zraired onspe.y9is. Complete drawing on reverse side. <br /> y Signed 7C Title: Date: <br /> 4�3,'t & <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date r' Area <br /> Pit or Grout Inspection by Data Final Inspection by Data f <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> IFEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> CHNFO fA .� • IL}. •U� ra G <br /> EH 1t-2e \ [ ll � <br />