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4 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 46$-94473q�Pb <br /> R PM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is h2�•aby atnde to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application ie tasee,.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 2 3 Lot Size/Acreage <br /> Owner's Name m(, c4 k t,f .._ Address _— � v o 2� Phone <br /> j Contractor <br /> �, i `J 4,ddress 7J-61 � License No. u-709phone <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REP C MENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L) OTHER ❑ <br /> Monitoring Well r} <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> nteca Dia. of Well Excavation Dia. of Well Casing <br /> n Industrial E-) Open Bottom ❑ Ma <br /> U Domestic/Private 0 Gravel Pack -----C�TFacy TxAa-ot,1CAa+ Specifications <br /> Public 13 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> 0 krigation Approx. De th d Eastern Surface Seal Installed by y O\ j <br /> 1 (Repair WAr U Type of Pump H,P. State Wo� o t— --- <br /> i I -.. Sealing Material 4 Depth <br /> i Well Desh ❑ Well Diameter <br /> iller_YAteriai__j_Depth <br /> TYPE OFI f� ORXt NEW'INSTAL GI TION REPAIR/ADDITION 0 DESTRUCTION (No eptic syW bew @d if pub icsewar is <br /> � available withi 200 feet: <br /> �Z, Installation will serve: Residence mmercial— Other <br /> Nit r of living units: � Number(( bedrooms <br /> Ctr�t Iter of soil to a depth of 3 lest: Water to yVapth <br /> i SEPTIC TANK O Type/Mfg - ^-¢sett JNo. Co xrtment I <br /> t Method f Dsspos <br /> PKG. TREATMENT PLT. ❑ ��� J tt� i <br /> t°ii Distance to nearest: Well �y.1_Y_._ Foungation P y Line 3� <br /> i LEACHING LINE (A No. & Length of lines r iQ nth i:e f <br /> TER BED ❑ Distance to nearest: Wetl_ r�o Foundation Property Line <br /> I j � <br /> I � <br /> EEPAGE PITS 11 Depth -Size Number <br /> SUMPS I$ Distance to nearest: Well - � - Foundation �0 Property Lina <br /> I <br /> I -DISPOSAL PONDS ❑ ` <br /> I + �t<aby 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 /> ides and regulations of the San Joaquin County <br /> FrQma 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 subcontracting signature <br /> rtifies 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 /> on laws of California." <br /> 1 e applicant mus call for a I required inspections. Complete drawing on reverse side. <br /> i /� I- , I— <br />' '! Title: -r u �u/ _ Date: - - — <br /> Signed �Z+ <br /> OR PARTM T USE ONLY <br /> Application Accepted by Date Xe rea <br /> ` Pit or Grout Inspection by Date Final Inspection by Dat1'� <br /> Additional Comments: - <br /> Applicant - Return all copies to:' SAN JOAQUIN COUNTY PUB HEALTH SERVICES <br /> ` ENVIRONMENTAL HEALTH VISION PERMIT/SERVICES <br /> \ 445 N SAN JOAQUIN, P O t6i 009, STOCKTON, CA 95201 <br /> I AM IVTfilta AMO T REMITTED CK REC IVE BY D E PERMI o- <br /> 9 <br /> f FO <br /> }i } 1 <br /> EM^,ala <br />