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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 O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made,to Sen Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in castpliance with San Joaquin County Ordinance No. 549 and 862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address City Lot Size/Acreage <br /> � t <br /> Owner's Name Address S_ l i ` /``'YL��'�� Phone <br /> AContractor dress, U S License No.� Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O out of Service Well O <br /> "PUMP INSTALt—Do <br /> SYSTEM RE AIR O OTHER O Monitoring Well ❑ <br /> DISTANCE TO NEAREST:`SEPTIC TANKSEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATIONAGRICULTURE WELL ER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WEEM AREA CONSTRU N SPECIFICATIONS <br /> O Industrial 'O Open BottomDia. a Excavation Dia. of Wall Casing <br /> Cl Domestic/Private 0 Gravel Packy ype of C sing_ SpecificationI'1 Public Cl Othera Depth of rout SealType of Grout <br /> I I Irrigation Approx. DSurface Seal Installed by <br /> Repair Work Done U Type of PumpH.P. Statq Work Done_ <br /> Wen Destruction O Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 10' REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sower is <br /> available within 200 feet.) <br /> V17 44— <br /> Installation will serve: Residence Commercial Other <br /> A494-AN <br /> /9„AN 144vig ��V <br /> �tM1 s <br /> Number of living units: Number of bedrooms_ O ry + IE- , <br /> Character of soil to a depth of 3 feet: +� Water table depth <br /> SEPTIC TANK. O Type/Mfg �' Capacity 2-0 ® No. Compartments <br /> PKG. TREATMENT PLT.O Method of Dispo 1 <br /> Distance to nearest: Well_ Foundation ,, <br /> ndation_! Property Line_1. <br /> LEACHING LINE ❑ No. b Length of lines %AATotal length/size N <br /> FILTER BED ❑ Distance to nearest: Well oundation Property'Lins <br /> SEEPAGE PITS I I Depth Size Z: Iyurpber <br /> SUMPS LI Distance to t: Well oundation��� Property 4iM_ l <br /> DISPOSAL PONDS O <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 la4s, 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 sjubject to workman's compensation laws of California.”Contractor's hiring or subcontracting signature <br /> certifies the following:"I unify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman'ts compensa- <br /> tion laws of California." <br /> The applicanst call f required inspections. Complete drawing on reverse side. <br /> Sigma Title: Date: ? 3_ <br /> �o `. FOR DEPARTMENT USE ONLY <br /> Application Accepted by `-"-"ti M J � i^'�^L. Dots �� Area 2 I 1 <br /> Pit or Grout Inspection by D�rate- Final Inspection by I Date <br /> Additional Comments: C / #C A#,J <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, ox 2009, Stkn, CA 95201 <br /> a, . <br /> AMOUNT DUE <br /> AMOUNT REMITTED K RECEIVED By TE PERMIT'N0. <br /> M <br /> 1 <br /> . EN 13-24INEV.+/9ao� �l —� <br /> EN 14.20 <br />