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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH 3RVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 Q <br /> j� (209) 468-3447 . 4 <br /> j?gMIT, EXPIRES I.. R � � <br /> (Complete in Triplicate) <br /> Application is hereby asde.to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is rade 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 /> i <br /> Job Address `3 -� 441, 7 �� 'D�6L_ e__ City S 72tAJ Lot Size/Acreage _- <br /> Johv, -r Vevoev- t <br /> Owner's Name _ Address _2 72 y `c'G>r!cyc. —_ Phone <br /> �� <br /> Contractor FL.��'_�©�' : .Address 2 V fie a License No.�2z /1 Phone <br /> TYPE OF WELL/PUMP. NEW WELL 0 WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well Gl <br /> PUMP INSTALLATION SYSTEM REPAIR 0 OTHER 13Monitoring Well <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 PR08LE AREA NSTRUCTION SPECIFICATIONS <br /> f_7 Industrial O Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> LJ Domestic/Private ❑ Gravel Pack 0 Tr 'Type of Casing Specifications <br /> ❑ Public Cl Other Delta Depth of Grout Seal Type of Grout r <br /> G Irrigation Approx, Dept Cl Eastern urlace Saul Installed by <br /> Repair Work Done U Type of Pump i H.P. State Work Done�� } <br /> Welt Destruction 0 Well Diame r l Sealing Ma Sal i Depth <br /> Depth ! Filler Mater4l i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION Ll DESTRUCTION INo septic system permitted if public sewer is <br /> / available within 200 lost.) <br /> Installation will serve: Residence v,-#Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg { Capacity No. Compartments I <br /> PKG, TREATMENT PLT. 0 Melh6dl of disposal- -- V <br /> Distance to nearest: Well Foundation Properly Line <br /> LEACHING LINE 0 No. A Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth i Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 - <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 Sen Joaquin'County 1 <br /> Home 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: "I certify that in the performance of the work for which this permit is issued, t shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The ap ust I r ui e�insp�ections. Complete drawing on reXprse aid l� <br /> Signa Titley CSS -- Date: u®T <br /> DEPARTMENT USE ONLYApplication Accepted by1,,.:�:O <br /> - - Date= -�-� �� _ Area <br /> Pit or Grout Inspection by <br /> Data Final Inspection:by DateAdditional Comments: a A%S/ r — <br /> f <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> !ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> i <br /> 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE # AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> i <br /> EM 1{•Ie E <br /> ti <br />