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IN <br /> APPLICATION FOR PERMIT <br /> U SAN J'OAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> J ENVIRONMENTAL HEALTH DIVISION No W, <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> NO <br /> yR11TT ESPIRES 1 YEAR FROM DAM-00-ED , <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 /> I r F <br /> II 3 ��• City Lot Size/Acreage <br /> Job Address j <br /> Phone <br /> Owner's Name 'i Address <br /> Contractor A--r <br /> Address _License No. 21199 Phone g <br /> o—�--- <br /> Service Well LI <br /> TYPE OF WELL/PUMP: NEW WELL LI REPLACEMENT ❑ DESTRUCTION ❑ Out Mo itoring Well <br /> it PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ID <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> iM. FOUNDATION AGRICULTUREWELL OTHER WE SIS PMU S <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CO N SPECIFICATIONS <br /> fl Industrial I� ❑ Open Bottom ❑ Mant Dia. of Well Excavation Dia. of Well Casing <br /> C3 Domestic/Private Cl Gravel Pack racy Type of Casing Specifications <br /> I'i Public I� I 1 Other 1 11 Delta° Depth b1 G'riiut Sear'^" Yyga-ot Grout <br /> I I Irrigation —.Appro . Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 00 Type of Pump H.P. <br /> State Work Done r <br /> { Scaling`atirrial bDepth <br /> Well Destruction ❑ Well Diameter <br /> II Filler Material i Depth <br /> pepth <br /> TYPE OF SEPTIC WORK: 'NEW INSTALLATION t I REPAIR/ADDITION l 1, DESTRUCTION (No septic system permitted it public sewer is <br /> II r{ available within 200 feet.) <br /> Installation will serve: Residence Commercial.�—1 Other" +'`s <br /> Number of living units: ;Number of bedrooms' r <br /> Character ofrysoil to a depth ofo3(feet:} - _"a_Water table depth <br /> SEPTIC TANK�a ❑ Type/Mfgt Capacity _ No. Compartments <br /> ' � � Method of pisposal 1 <br /> PKG. TREATMENT PLT. ❑ t € _ <br /> i Distance 10 nearest: Well. dation­­ Line <br /> IE � a <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED II C3 Distance to nearest: Well { Foundation Property Lina <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ali LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 I .` <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, I shall employ persons subject to workman's compensa- <br /> tion laws of California. <br /> Theapplicant �I st call for all required inspect' ns. Complete drawing on reverse sid . <br /> Signed X Ti <br /> Date: <br /> DEPARTMENT USE ONLY <br /> Application Accepted by •' r Date �� Area <br /> I' <br /> Pit or Grout Inspection by , Date Final Inspection by Date <br /> Additional Com ments: <br /> t <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 /> ! FEE AMOUNT DUE � AMOUNT REMITTED CASH CK 4 RECEIVED BY DATE PERMITN0. <br /> INFO <br /> � f Q� <br /> r EH 13-21 tREV.IIK51 .t �� �p"'].S D i L7 <br /> EH 14-25 <br /> !11 1 <br />