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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 0 BOX 2009, STOCKTON, CA 95201 <br /> PERM T E%PIRES 1 YEAR FR M D TE I S <br /> (Complete in Triplicate) <br /> uin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Ayplicatfon is hereby raede,to� Joaquin CSan J Qy for a permit to construct and/or install the work herein described. This <br /> application is Public Hein alth services. `I <br />� Joaquin County <br /> t Lot Size/Acreage <br /> 11-� City <br /> Job Address <br /> Phone <br /> Address <br /> Owner's Name <br /> ICr�. 1_iCense No Phone <br />+ r Address: /Q./ `eS� <br /> I ConlracltN WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service Well ❑ <br /> NEW WELL 13 Monitoring dell ❑ <br /> TYPE OF WELL/PUMP: SYSTEM-REPAIRrC7 - OT ❑ <br /> PUMP-INSTAL-L-ATION�-❑-ri--►*�"�"�'�"'r �� DISP PROP, LINE <br /> k a 'SEWER LINES PITS/SUMPS <br /> DISTANCE TO NEAREST. SEP ANK �� AGRICULTURE WELL OTHER WELL <br /> —�- <br /> FOUNDATION, <br /> TYPE OF WELL PROBLE STRUCTION=SPECIFICATIONS�`" <br /> INTENDED USE Dia, of Well Casing <br /> or ell Excavation <br /> L3 Industrial <br /> [I Open Bottom © Man a Specifications <br /> Ci Gravel Pack racy Type of Casing <br /> L1 Domestic/Private Depth of Grout Seal Type of Grout <br /> I'1 Public <br /> 1.1 Other n Delta x. <br /> I I Irrigation prox. Depth I I Eastern Surface Saai installed by _ <br /> H.P. <br /> Stat;Work Done <br /> Repair Work Done -w Type Of Pump ming Material i Depth <br /> Well Destruction ❑ Well Diameter � — hiller Material i Depth <br /> Depth <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION l I REPAIRlADDITION I I DESTRUCTION INailablerw thin 200 feec syme Lled+f public sewer is <br /> Installation will serve: Residence Commercial Other,. <br /> j Number of living units: Number of bedrooms Water table depth <br /> Character Of soil to a depth of 3 feet: No. Compartments , <br /> I SEPTIC TANK. ❑ Type/Mfg �----CspaCity -- <br /> } Method of Disposal <br /> PKG. TREATMENT PLT.❑ r `Well Property�,. ?,Foundation Perty Line <br /> Distance to nearest: v r <br /> 10 <br /> iI Total length/size <br /> LEACHING LINE C1 NO. 5 Length of lines Property Lina — <br /> I FILTER BED ❑ Distance to nearest. Well Foundation cy <br /> ! 11 Depth Siza Number <br /> SEEPAGE PITS property Lina <br /> SUMPS LI Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ <br /> f 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, end <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "1 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 h+ring Or sub-contracting signature <br /> certifies the following: "1 certify that in the perlormancmploy parsons subject to workman's companss <br /> a of the work for which this permit is issued, I shall e <br /> tion laws of Coliforms." <br /> The applican t call f I r ions. omplete drawing verse Ida. <br /> Title: Date: <br /> Signed <br /> DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by 3 <br /> r Date Final Inspection by Data <br /> Pit or Grout Inspection by <br /> Additional Comments: <br /> 1 Applicant - Return all copies to:""San Joaquiti County P`ublic'Health ServicesY '- <br /> Environmental Health Permit/Services <br /> I 445 N San Joaquin, p O Box 2009, Stkn, CA 95201 <br /> FEE CK RECEIVED BY DATE VER <br /> INFO ND. <br /> AMOUNT DUE AMOUNT REMITTED <br /> . EH 13.24 ittEV.1/n 6a <br /> EM 14.26 <br />