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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 0 BOX 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 San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. --� <br /> �3 i' j •9 i <br /> Job Address <br /> ' � tea ( ,/1� City - Lot Size/Acreage-32 f ,f'°t-11 <br /> Owner's Name L 1 r-) Address Phone <br /> �II` ' /moi �-� CJ . __< ��L M-dicense PhoneContractor � / — (= � � Address No. <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well O <br /> PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well C1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ._ <br /> INTENDED USE TYPE OF WELL BLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial O Open Bottom Wo Mantim*0 f yJ 1JWq*�� =SERWtell Casing <br /> [I Domestic/Private O Gravel Pack O Tracy �0 co...�..•* es�at�r[t iliViCTAl1�,Specifications <br /> I'I Public Cl Other n Delta Depth o_f Grout Sell Type of Grout <br /> I I Irrigation Approx. Depth I 1 Eastern <br /> Repair Work Done U Type of Pump H.P. State Work Done_ ^Q <br /> Well Destruction O Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( I DESTRUCTION I I INo septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: R once�-- Commercial_ Other <br /> Number of living units: Number of bedrooms -� <br /> Character of soli to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.O Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE C1 No. 6 Length of lines Total length/size <br /> FILTER BED O Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS IN---Mpth _k- Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <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 laws, and <br /> rules and regulations of the San Joaquin County <br /> H#e 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: "1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tionCalifornia." <br /> The applicant st all or alf)req ed in ct F omp a drawing on - verse side. ' <br /> Sig �� Ti "_ Date: <br /> OR EPARTMENT USE ONLY <br /> Application Accepted by — - Date 1-11 Area p <br /> Pit or Grout Inspection by Date Final Inspection byDate /� 9 <br /> Additional Comments: e 44 A., /�'�41 / . <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DVE AMOUNT REMITTED CKS RECEIVED BY DATE PERMIT'N0. <br /> ECASH <br /> INFO <br /> 2-4. EH 17.211•�a 1(REV. i M s l J C r 6:_ tea Z—U- 3^ (�LJh <br /> ✓ <br /> H <br />