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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONI[ENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT FIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to Baa Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> yob Address d 4 Citi D /'*Wl Ot Size/Acreage <br /> oop, . �7C <br /> Kwner's Name / /�J ddressQom , �Ly ,r�i'�C�fit, <br /> ontractor lly/��- Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACE NT ❑ DESTRUCTION O Out of Service Well O <br /> PUMP INSTALLATION O �LES <br /> YSTEM EPAIR O OTHER O Monitoring Well O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER DISPOSAL FLD. PROP. LINEFOUNDATION AGRICW L OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AA <br /> ION SPECIFICATIONS <br /> C7 Industrial O Open Bottom O Mantecaxcavation Dia. of Well Casing <br /> Cl Domestic/Private O Gravel Pack O Tracyg_ Specifications <br /> Il Public Cl Other n Deltat Seal Type of GroI I Irrigation _ Approx. Depth I I Easternn lied byRepair Work Done 0 Type of Pump HState Work Done_ <br /> Well Destruction O Well Diameter &ling Material i Depth <br /> M <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INS A LATION 1,1 REPAIR/ADDI ION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> y, G , , vk• 6 :v il.1blh ithin 200 leet.l 1 <br /> Installation will serve: Residence__Ie' Co1nmercial_ Other rT " <br /> Number of living units: ( Number of bedrooms 4 <br /> 8haact of soil to a th of 3 feet: Water table depth ?O <br /> SEPTIC TANK. . Type/Mfg l- Capacity Ulf No. Compartments Z' <br /> PKG. TREATMENT PLT.0 � c fi Method of Disposal <br /> Distance to nearest: Well (20.4oundation_ rte_—_� Property Linn XQ1- \ <br /> EACHING LINE No. 8 Length of lines _ _ Total length/size— <br /> FILTER <br /> B O Distance to nearest: Well toe Foundation ,_t D Property Line b(5 <br /> SEEPAGE PITSr I I Depth ` Siie N1,rmber <br /> I�/ ('0d � Distance to nearest: We _1S foundation—�D Property Line \ `v <br /> DISPOSAL PONDS O ." <br /> `-- I hereby certify that I have prepared this application and that the work will be done in accordance with'SamJoaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Homs owner or licensed agent's signature certifies the following: "I certify that in the performancb 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 compensatior>laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the fo#owing:"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 a ant must 11 for r fired ' ctions. Complete drawing on reverse si* Q <br /> Signed Title: <.r 11L'/ /t' Date: /O '"� <br /> OR DEPARTKAENT USE ONLY <br /> Application Accepted byAft Date ` 1 Z Area D �— / - <br /> � 9 <br /> Pit or'Grout Inspection by Date Final Inspection Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO `/�� //�,/, G/�J <br /> • EH/ 111EV.1--]0 i w m) L t Q // ! l ,� e� /e/c, <br /> c, / <br />