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APPLICATION FOR PERMIT <br /> 11 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOR 2009, STOCKTON, CA 95201 <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 Joaquin County Ordinance No. 549 an 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Service <br /> Job Address tv (V n City ;.ot Size/Acreage 1 <br /> (�9Owner's Name ddress T"C 41 F 169 K �t/�/� Phone <br /> Contractor Address/ License No., J±y� Phone ` <br /> TYPE OF WELL/PUMP: =TELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LI ES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULT RE ELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM 4AREANSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Mantec . of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracye of Casing Specifications <br /> I'l Public El Other n Deltapth of Grout Seal Type of Grout <br /> I 1 Irrigation Approx. Depth I I East nface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I 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: Number of bedrooms L _ <br /> Character of soil to a depth of 3 feet: 4 11 Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line1. <br /> LEACHING LINE Cl No. & Length of lines Total length/size + <br /> FILTER BED ❑ Distance to nearest: V a<1-,L&Q Foundation Property Line <br /> SEEPAGE PITS 11 Depth z J Size er _ <br /> SUMPS LI Distance to nearest: Well tM', , Foundation.,215 Property Line 177 6 <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 1this 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 subcontracting 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 applicany7nust call for equired in ctions. Complete drawing on reverse side. <br /> lam) f <br /> SignedTitle: 61e14f�r _ i Date: <br /> 4 I/- FOR DEPARTMENT USE ONLY <br /> �Oxl <br /> Application Accepted by " Date / Area <br /> Pit Grout Inspection by �'Date ��� inal Inspection by -"� Date��� <br /> Additional Comments: <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 95201FEE .�. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> EH 13-211REV.rinse -7O <br /> EH;ass of /I 1 <br />