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k <br /> 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 I YEAR FR M DATE <br /> ISSUED— <br /> (Complete in Triplicate) i <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 R/mulations of San <br /> Joaquin County Public Health Servic +/ 4�Add,..s <br /> Lot Size/Acreage // l-k (� <br /> Job Address City � �/'�} <br /> J90 PhD 0Owner's Name OeoLE& sf3! * �`y' <br /> 1 r �1 / S3 �/ / O � / <br /> Contractor r Address V License No. Phone <br /> TYPE OF WELL/PUMP:,. NEW WELL❑....•_.�_. _WELL REPLACEMENT ❑ DESTRUCTION f l Out of Service Well ❑ <br /> - "- ...� - �.�, �14onitoring..Well <br /> �`" PUMP INSTALLATION ❑ 'SYSTEAA REPAIR C3 OTHER❑ ❑ <br /> DISTANCE TO.NEAREST:.SEPTIC TANK SEWER LINE DISPOSAL FLD. PROP. LINE <br /> t } FOUNDATION AGRICULTU OTHER WELL PITS/SUMPS <br /> INTENDEDUSE ,f:YPE OF WELL PROBLEM ARE ONSTRUCTION SPECIFICATIONS <br /> C7 industrial ❑ Open Bottom Om ant ie. of Wall Excavation Dia. of Well Casing <br /> �l <br /> Domestic/Private ❑ Gravel Pack cy Ype o Casing_ ^` Spacifcations <br /> Il Public C3 Other In Delta l Depth of Grout Seal Type of Grout <br /> I I lrrigation Apprax. Depth I I Eastern Surface Seul Installed by } <br /> . ... £ t <br /> Repair Work Done U Type of Pump H.P. State"Work Done <br /> Well Destruction ❑ Well Diameter $gal nB Material i Depth <br /> a ; <br /> Depth tiller Naterial Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION I DESTRUCTION I I INo septic system permitted if public sewer is <br /> ! a4ysilabl6"withi feet.l_� � � ff !i <br /> t I�JJ 7 <br /> Installation will some: Residence ti Commercial Other <br /> Number of INting units: Number of bed ms ' <br /> r <br /> Character of soli to a depth of 3 feet: Water table depth <br /> SEPTIC TANK.. ❑ Type/Mfg Ca ity No. Compartments f <br /> PKG. TREATMENT PLT. ❑ f Method of Disposal t <br /> Distance to nearest: Well I V d &?Foundation Property Line 1 <br /> LEACHING LINE ❑ No. & Length of'lines Total length/size <br /> FILTER BED ❑ Distance to nearest: ou ation Property Line <br /> h� 1.1 <br /> SEEPAGE PITS` 11 Depth Sire tuber <br /> SUMPS # LI Distance to rest: Wallrf _ Foundation 0 Property Line <br /> i DISPOSAL PONDS ❑ <br /> `� u. ,s i <br /> 1 hereby certify Ghat I have-prepared this application-and that the work will be done in'itccordance With San Joaquin county ordinances, state laws and <br /> rules and regulations of the San Joaquin County <br /> Horne owner or-licensed agent's signature certifies the following: "I certify that in the performance of the wbrk-forwvhich,this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the fofio"ng: "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 Californla." I <br /> The applica must call f requir inspections. Complete drawing on reverse side: + r <br /> r , € c f L <br /> Signed title: Date: <br /> gs OR PARTMENT USE ONLY 4 <br /> Application Accepted by Date ��` 2-'• 'Area 77 ? <br /> Pit or Grout Inspection by Date Final Inspection by ' ..4 Date GST <br /> Additional Comments: <br /> Applicant - Return--all-copies--to.,--San-Joaquin County Public Health Services <br /> Environmental Health Permit/Services s <br /> 445 N San Joaquin,_P_O Box 2009,,,�Stkn,, CA_95201 _t. � .r <br /> FEE AMOUNT DUE AMOUNT REMITTED �K RECEIVED BY (]ATE PERMIT NO. 4 <br /> INFO CASH � . <br /> . EM,3-r4lttEv.ti,N61� oo rod 3 Z -333 <br /> EH 14-M <br />