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APPLICATION FOR PERMIT c <br /> rw4 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ND <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> No <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete 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 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 / %10 #/tz City. Lot Size/Acreage 'Z 4-C kx� <br /> Owner's Name r�y/dK-f/+ Address Z/�U AL I C � Phone <br /> j£ DQc be, Sy-7_ <br /> Contractor It :T Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL O WE L REPLACEMENT DESTRUCTION D Out of Service Well D <br /> PUMP INSTALLATION D YSTEM REPAI D OTHER D Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE ELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CON TR CTION SPECIFICATIONS <br /> n Industrial O Open Bottom ❑ ManteASurface <br /> ell Excavation Dia. of Well Casing <br /> Cl Domestic/Private D Gravel Pack ❑ Tracy TyCasing Specifications <br /> I'I Public fl Other 1� Deltaf rout Seal Type of Grout <br /> I I Irrigation —.Approx. Depth I I EasterSe I Installed by <br /> Repair Work Done U Type of Pump State Work DoneWell Destruction D Well Diameter l & th <br /> Depthl b Dep h <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence '�Commercial_ Other <br /> Number of living units: _L_ Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> E \ <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments `rN <br /> PKG. TREATMENT PLT. D Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size _ Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ / <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 <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 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 permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applica ust call for all required2n- <br /> ..Complete rawing on reverse side. <br /> Signed X Date: `® <br /> R DEPARTMENT USE ONLY ID <br /> Application Accepted by Date ­ 1 Area ` S <br /> � -�-r �t <br /> Pit or Grout Inspection by Date Final Inspection 6 y <br /> Additional Comments: c6S� C <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> CK <br /> IFEE OUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> Av U <br /> + EH .211REV.�ixs1 J �/r / y <br /> EH";x•28 f <br />