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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH�DIVISION <br /> '445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, ,STOCKTON, CA 95201 <br /> 4� <br /> PERMIT EXPIRES-1 YEAR FROM DATE ISSUED <br /> (Completf3' 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 frith San Joaquin County Ordinance No. 51+9 and A8462 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> 3'1302- 0 w City Lot Size/Acreage <br /> Job Address <br /> l /l A o ��I Pkhone } <br /> I I I t . I <br /> - -- : k <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT [7 DESTRUCTION or err ce eii u <br /> Monitoring Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM RE IR ❑ OTHER ❑ r+ <br /> DISTANCE TO NEAREST. SEPTIC TANK SEWER LINES DIS AL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL HER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUC ON SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Mantecs Dia.'of ell E cavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy T of Casin Specilications <br /> I'1 Public n Other �I' F1 Delta epth of Gro t Seal Type of Grout <br /> t I Irrigation Approx. Depth I I Eastern 1` Surface Seal Installed by R <br /> Repair Work Done (] Type of Pump H.P. State Work Done — [J <br /> Sealing Material A Depth <br /> Well Destruction ❑ Well Diameter <br /> Depth Filler Material i Depth <br /> r. O <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f REPAIWADDITION I I DESTRUCTION_ I )_flee ;split system permitted it public sewer is <br /> available within 200 feet.) <br /> Injtallation will serve: Residence -_commercial_ Other <br /> Number of living unit Number of bedrooms <br /> � t 2 '� i s i Water table depth <br /> I Character of sell to`a,depth of 3 feet: _ <br /> SEPTIC TAk - `-❑! Typal Mfg ' Gap�ac+ty~• Na Compartments <br /> -r.... .�.�.....w..,,.--..� i. _- <br /> PKG;`TREATMENT PLT.❑ .1 - Method of Dispo P <br /> `.F Distance ttiwnearest: k—Well. oundation U Property Line "t <br /> f = iiy iA. 6 1 - <br />+ LEACHING LINE ❑ No. Length of lines. `� ' Tot I I ngth/size <br /> FILTER BED Cl Distance to nearest. Well . Foundation 'A Property Line <br /> SEEPAGE PITS 1 1 Depth s Mf t <br /> 2 Size N r <br /> �._ _ ; <br /> SUMPS LI Distance to near t: well 4 Foundation Property Lint <br /> DISPOSAL PONDS ❑ ;,V� <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, an <br /> rules and regulations of the Sen Joaquin County T <br /> Home owner or licensed agent's signature certifies the following: "I canify 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 taws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I cir dy chit 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." t { <br /> r The applicant t call for all r ed inspect' s: Complete drawing on reverse side. a �y <br /> i r > _ Date: el ! - <br /> Signs Title: r <br /> �i <br /> or <br /> > DEPARTMENT USE ONLY <br /> 9 " r` ` Date �r Area <br /> 4 A ication Accepted by <br /> Pit or Grout Inspection by Date )nal Inspection by Date <br /> ddidonal Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services ���/A� <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Hoa 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO CASH '� <br /> . EH 15.31IREV.I/R51 �� L�/� <br /> � 1 <br /> EN 11.16 • <br />