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APPLICATION FOR PERMIT �S <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES y� � 1 1:.#.- <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 ((( <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FRAM 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 /> Services. <br /> "Job Address 67Z_/y� nCity 5/0Q " <br /> ot Size/Acreage <br /> XOwner'sName 0"Address <br /> Phone <br /> G wo e r' <br /> N. Contractor ___ _ ___ Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n- DESTRUCTION 0 Out of e Well ❑ <br /> NSTALLATION ❑ SYSTEM REPAIR ❑ Monitoring Kell <br /> DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES Di LD. PROP. LINE <br /> FOUNDATION ULTURE WEL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM UCT10N SPECIFICATIONS <br /> n Industrial ❑ Open Bottom anteca Dia. of Wel ation Dia. of Well Casing <br /> Cl Domestic/Private Cl Gravel P U Tracy Type of Casing Specifications <br /> Il Public 'or t l Delta Depth of Grout Seat <br /> Typa of Grout <br /> I i Irrigation _Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair 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 1 REPAIR/ADDITION I 1 DESTRUCTION lNo septic system permitted if public sewer is I <br /> available within 200 feet.1 <br /> Installation will serve: Residence— 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 <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Welt Foundation Property Line <br /> DISPOSAL PONDS 0 <br /> I hereby certify that I have prepared this application and that the work wilt 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 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 followinEator <br /> " rtify 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 Califor <br /> The applicant;u u' d ` pecti Complete drawing on reverse side, <br /> xSigned X r Title: Dater r2-- 1 <br /> FOR E Rl'f1AENT USE ONLY <br /> Application Accepted by 47K, Date 2 Area <br /> Pit or Grout inspection by Date Final 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 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASCK H RECEIVED BY DATE nnn PERMIT'N0. /�' <br /> . !ill 13-24 IREV.i/n ss �� } ®V M f� r '2 �1 �y �f,.,/�j.+ <br /> EH 14.26 ���.••JJJ J t \ Lr l t ff/ <br />