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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> 1!J MIT EXP1fl9S I YEAR kA09 DATE IS§IE$ <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a Permit to construct end/or install the work herein described. This <br /> application Is made in cospliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. �✓ S � _ <br /> Job Address � <br /> /(� /v ✓`a LCity �1�� t Size/Acreage <br /> fieAddress Phone <br /> Owner's Name � '- <br /> Contractor Address License No. `Phone <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well [1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE «` <br />._ FOUNDATION AGRICULTURE WELL OTHER W . I S/SUMPS <br /> INTENDED USE OF WELL PROBLEM AREA CONST SPECIFICATIONS (A <br /> F1 Industrial ❑ Open Bottom teca of Well Excavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack 0 Tr f Casing Specifications ti <br /> L7 Public I:11 Other Delta Depth of r eal Type of Grout <br /> GI irrigation <br /> pp, <br /> Depth ❑ Eastern Surface SOLI Installe <br /> Repair Work Done L3 Type of Pump H.P. State o ne _ <br /> Welt Destruction ❑ Well Diameter Sealing Material i Depth ? <br /> Depth ._ _ Filler Material i Depth L. <br /> TYPE OF SEPTIC WORK: NEW INSTAL LATIO REPAIR)ADDITION 0 DESTRUCTION Cl (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial Other ; <br /> Number of living unite: Number of be ooms a �' <br /> Character of soil to a depth of 3 feet: �� �� Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg �C e,�'2 7,Z Capacity No. Compartments <br /> PKG, TREATMENT PLT. 0Method of Disposal <br /> Distance to nearest: Well Foundation. Property Line <br /> LEACHING LINE No. b Length of lines Total length/size <br /> Q � <br /> Zy— <br /> FILTER BED n Distance to nearest. Well Foundation Property Line <br /> SEEPAGE PITS I I Depth -SizeNumber <br /> t:.1 <br /> < <br /> SUMPS Distance to nearest: Wel{ 4-1/ Foundation %�) T Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby cenify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> r <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following- "I cartity 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: "I cenify that in the performance of the work for which this permit is issued, I shall employ persons subject"to workman's Compania- <br /> tion taws of California." <br /> The applicant must call for all regwr inspections. Complete drawing on raver <br /> Signed X - — Title: Date: <br /> F DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection bye Data Z <br /> Additional Comments.- <br /> Applicant <br /> omrr+ents:Applicant — Return all copies to, SAN JOAQUIN COUNTY PUBLIC H19ALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES \\\ <br /> 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 85201 } <br /> FEE AMOUNT DUE OUNT REMITTED CK RECEIVED BY DATE PERMIT"N0. <br /> )NFO VA�H { h'N <br /> . EH 13-24 IREV,I/HSS ta� t t3 EH1{•2e <br /> 1 <br />