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APPLICATION FOR PERMIT w <br />` <br /> SAN :TOA@UIN COUNTY PUgt"`IC HEALTH SERVICES S <br /> ENVIROf111dENTAL HEALTH DIVISION <br /> 1601 9. HAZEtTON AV9 ; PHONE (209)468-3420 <br /> r L r <br /> P Q BOX 2009 t: -SfOCKTOg, CA 95201 <br /> %P RES 1-YT R 9 D <br /> (Complete in Triplicate) <br /> Appiictitiori ie here* imide tp Srih Joaquin totitity for d� <br /> application is afiede iii celnplihitob with t3 ;7oequiit County Ordiha£di a No; 549 and 1862 and the Rules find Regulations of San <br /> permit to construct and/or install the cork herein described. Th' <br /> KisJoaquin County Public Health $ervic�rt: <br /> 7 <br /> Job Address C,J � <br /> City Lot Size/Acreage <br /> �Dwnir'd blame t 1 <br /> ddress _ Zb <br /> f } Phone <br /> �Coftacltii r 4 t •-�. I E <br /> 'ry � UMP: � <br /> PE OF'WELL/PNEW.WELL ❑ ----�Phone <br /> ;' WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well Ll <br /> PUMP INSTALLATION D! SYSTEM REPAIR Ll' Monitoring well <br /> DISTANCE TO N AREa 9l: ft UNK , S9WE"# LINtt ' . OTHER p [.7 <br /> -- DISPOSAL FLD. PROP. LINE <br /> )A !ON AGRICULTURE WELL — OTHER WELL PiTS/SUMPS <br /> INTENDED USE TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Open Bottomi <br /> n Industrial ❑ <br /> - ❑ Manta`tca Dia. of 1Nefl Excavation <br /> Cl Domestic/PrlVate b Gravel Pack ' El *racy T Pia. of Well Casing <br /> i'I Public i Ybe of Casing 1 <br /> fa Other 1 fSpecifications <br /> l Datta Depth of Grout Seat <br /> i I Irrigation �.,Approk. Depth I i Eastern Type of Grout <br /> Repair Work Done U * Suriace Seal Installed by <br /> YPe of pump H.P. . , i <br /> Well Destruction 0 Well Diameter ,State Work Done_ <br /> Sealink Aateriail:&',DEpth i <br /> Depth Filler fitterial & >5epth i`� <br /> •TYPE OF SEPTIC WORK: NEW INSTALLATION I I ' REPAiAYADDITION ! I pE5TRUCTION r <br /> ' !! iNo septic system permitted if public sewer is �Q <br /> Installation W;II abtve:. haild@ticb , 1_•--_ --�- . -- -- j available within 20')0 feet.F <br /> CtsMen6rdial— Other <br /> Number of living unit$: Nunibei of bedrooms _ <br /> Character of soil to i depth of j [eel: . { <br /> SEPTIC TANfC ^ C)❑ Type/Mfg Water table depth <br /> PKG. TREATMENT PLT: t CaSpacitji _---;- Nb. Compartments J ` <br /> r <br /> Method of Disposal v <br /> > Distance to he9rest: I Well Foundation <br /> --- � Propdrty Line <br /> LEACHING-LINE,.� I Li : No. i Length of Imes € <br /> FRTERl3Ep i Cl '.Distance to nt#erest: ;Weil Total length/size <br /> Foundation _ Property Line <br /> SEEPA(;E PITS- I I I Depth <br /> SUMPS - ' Site Number <br /> El ;Distance t6 neareti: 1 Wait�_ Foundation_ <br /> DISPOSAL PONDS El �� Property Line <br /> I hereby certify that i hevb pre <br /> partfd this applicatibn.9nd Shat the work will be dons in a <br /> rules and regulations of the loan Joaquin County ccortlance with San Joaquin county ordinances, state laws, and' t <br /> Home owner or Licensed agent's 'signature certifies the following;°"I certify that In the performance of the work for Which this permit is issue I <br /> employ shy per,lon In ouch rth Lhaitr as td bbcom6 subject to workmi sn's corrlpensation laws of California."Contractor's hiring of sub-contracting signature I} <br /> certifier tfie foNoviring:"!certify that in the rioinriance bf the work far which thio emit is issued, l shall eat► to d, I shall not <br /> tion laws of C r a.''' i <br /> I j P employ parsons subiect to workman's compense- <br /> The apptican'roue calf r at r 6Q, t <br /> ctidrie. ComPleke drawing oh reverie s <br /> Ksionddl,' <br /> �jf�- r "z, <br /> Date: f j <br /> ? t ENUSE bNLY <br /> P Y <br /> Application Acee tad b ' <br /> Data -Area P <br /> Pit or Grout Inspoction by �. <br /> }' bate �� Final Inspection by <br /> Additional Carnrneitte: ; DateC1 <br /> /E' <br /> i <br /> Applic�ent.-rltetairs e]1 r opie6 to Sett JC' quip Count}f,Public iealth <br /> Servicea. ktvironrlte'n l Hiyalth permit/Sr~ivice5 1 YOB <br /> 16 .. E. Aateltan Ave,i`P 0 Box 2009; Stockton, CA 95201 P►^i�1�pt <br /> FA oUNT DUE AMOUNT AEMITTEO <br /> INFO C H RECEIVED BY <br /> DATE PERMIT'N0. <br /> H x321 iREV,t/ti7i `�— <br />