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R � 1 <br /> SAN JOAQUIN COUNTYPUBLICH EALTH SERVICES <br /> ENVIRONMENTAL11 <br /> ON <br /> 445 N, SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT =IRES 1 YEAR FROM DATE 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 compliancelxith San Joaquin county Ordinance No. 5G9 and 1862 and the Rules and Regulations of an <br /> Joaquin County Public Health Services. f <br /> City Lot Size/Acreage <br /> Job Address I e (� _ '22 , <br /> Address Phone <br /> �� - <br /> Owner's Name I t ti <br /> dress • • � 'l�'icense o <br /> Contractor DESTRUCTION ❑ Out of Service Well ❑ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT r Monitoring Well L� <br /> SYSTEM REPAIR El OTHER ❑ <br /> PUMP INSTALLATION \ i <br /> ki SEWER LINES DISPOSAL FLD. PROP, LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br /> FOUNDATION AGRICULTU WELL OTHER WELL <br /> .-INTENDED.USE TYPE OF WELL PROBL MAR CONSTRUCTION SPECIFICATIONS. pia. of Well Casing <br /> El Industrial P Open Bottom C3 Mani Dia. of Well Excavation {� <br /> Type of Casing_ Specifications [�, <br /> C1 Domestic/Private Cl Gravel Pack ❑ Tr e yp e Type of Grout <br /> Cl Public i-1 Other alta Depth of Grout Seal <br /> i I Irrigation —.Apstrox: Depth I I Eastern ��. Surface Seal Installed by <br /> !YN <br /> Repair Work Done. _L3 Type of Pump <br /> H. State Work Done <br /> i Ing Material & Depth <br /> Well Destruction ❑ Well Diam <br /> Depth Fill r Material & Depth <br /> IM. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I RE PAIRIAD�ITION I l DESTRUCTION I t alvailable�wi within 20c system 0 feet-1, <br /> it public sewer is <br /> Installation will serve: Residence Commercialther <br /> Number of living units: Number of bedrooms x Water table depot <br /> I Character of soil to a depth of 3 feet: „ <br /> � Capacity 0 No. Compartments <br /> SEPTIC TANK D Type/Mfg 4 Method of Discos <br /> PKG. TREATMENT PLT.❑ I r <br /> f Distance to nearest: Well �] � Foundation Property Line <br /> or <br /> C fir <br /> LEACHING LINE Cl No. & Lengthof lines <br /> Total length/size <br /> FILTER BED n Distance to nearest:_ ell Foundation Property Line <br /> SEEPAGE PITS 11 Depth <br /> tl Size Number <br /> SUMPS LI Distancei to nea st: Wet!_ Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and this the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin county •. 'permit is issued, 1 shall not <br /> Home owner or licensed agent's signat.ure certifies the following: "I dertify;.thal in.the performance of the work for which this <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: "1 certify that.in lihs 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� l �— <br /> ' The applicant ust call for equiredl ' spp'c <br /> Signed Title: <br /> Complete drawing o reverse side. <br /> i f—k <br /> C' Title: I Date: <br /> �. FOR DEPARTMENT USE ONLY ^J <br /> Date �� � r� � Area <br /> Application Accepted by `` f r7 X/ <br /> II Date Final Inspection by Data D <br /> i Pit or Grout Inspection by iI <br /> Additional Comments: <br /> i <br /> Applicant - Return all copie to: San`Joa uin County Public Health Services <br /> * -r Envirbnmental Health Permit/Services ^ <br /> L r„� '•.f� 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE S 9 ��EtRECEIVED f3Y DATE PERM17'NO. <br /> INFO /AMOUNT DtJE* AMOUNT REMITTEb <br /> + £H 53-34IREV.iinSi <br /> f <br /> t EH 14.26 <br />