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APPLICATION FOR PERMIT <br /> two SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 a <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> : <br /> PERMIT E3rPIRES_1 Y FROM D T S . <br /> (Complete in Triplicate) <br /> 4. <br /> Application ie hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> e with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> application is made in complianc <br /> Josquia county public Health services. <br /> Job Address 2 .1- FL/,yel Ad 2D City <br /> Gr Lot Size/Acreage -t,A C. <br /> 1il�r Irl n n a p���._ Address <br /> _E0 ads A'L Phone 7� L <br /> Owner's Name - — <br /> Contracts L- Address 1:�.. License No. '��Y7ln _Phone <br /> i WELL REPLACEMENT In DESTRUCTION ❑ Out of Service Well L1 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ Monitoring well Ci <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> i FOUNDATION AGRICULTURE WELL -OTHER-WELL.— PITS/SUMPS _ �\ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> 0 Industrial O Open Bottom ❑ Hamate Dia. of Well Excavation Specilicationa <br /> Cm <br /> l Doastic/Private C1 Gravel Pack ❑ Tracy Type of Casing_ <br /> !'l Public Cl Other n Delta Depth of Grout Seal - —Type-of-Grout <br /> I I Irrigation Approx. Depth I I Eastern Surface Saul installed by <br /> Repair Work Done L3 Type of Pump H.P. State Work Done <br /> i Sealing Material A Depth <br /> Well Destruction ❑ Well Diameter <br /> / <br /> Depth <br /> )Filler Material i Depth <br /> k TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRlADDITION I I DESTRUCTION I l INO available witic hin loststem .) it public sewer is <br /> rt <br /> Installation will serve: Residence✓ Commercial_ Other _D P_AGJ/A!G <br /> Number of living units: Number of bedrooms . `1 <br /> Character of SON to a depth of 3 feet: &I `� - Water table'depth l <br /> f <br /> SEPTIC TANK ❑ Type/Mfg 9-L Capacity. 2-a d No. Compartments Z �� <br /> 1 <br /> ` PKG. TREATMENT PLT.0 Method of Disposal <br /> Distance to nearest: Well 106..' Foundation__1�__�- Property Line- <br /> J2O <br /> LEACHING LINE No. a Length of linea Total lengshlsize r <br /> FILTER BED 0 Distance to nearest: Well 1 00 Foundation Property Lina <br /> SEEPAGE PITS W Depth a-S _Size rr• Number <br /> SUMPS Lt Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 a <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, and <br /> rules and regulations of the San Joaquin County 1 <br /> Home owner or licensed agent's signature cenifiss the following: "I certify that in the psrfdrma ce 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 sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permits issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete-drawing on reverse side. 'r <br /> J <br /> Signed - Title: r�/ri''t--•.�....... _ Date: <br /> I I <br /> r If r T ! FOR DEPARTMENT USE ONLY <br /> Application Accepted by/-� ease `q Area Z <br /> or Grout Inspection by ata Final ( y Dots_ 1�� 7 <br /> Additional Comments: -- <br /> L Applicant - Return all copies to: San Joaquin County Public <br /> + Environmental Health Permit/Sery cetd <br /> t 445 N San Joaquin, P. 0 Box 2009, Stkn, CA 95201 <br /> k <br /> FEE AMOUNT DUE AMOUNT REMITTED CAS RECEIVED BY DATE PERMIT•NO. <br /> INFO <br /> . EM13-24 { <br /> 2�IREV.tiK51�. � <br /> EH 14.70 <br />