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Y APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> { ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468--3420 <br /> P O BOX 2009, STOCSTON, CA 95201\10 <br /> PERUIT EXPIRES 1 YEAR FROM DATE ISSUBD <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 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Seivices. <br /> X/Job Address ° City Lot Size/Acreage <br /> Owner's Name Q�VG04!��Chddress Phone a� <br /> P Contracior 0e Address License No. Phone <br /> TYPE OF WELL/PUMP: EW WELL ❑ WELL REPLACEMENT [1 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALbKQN ❑ SYSTEM REPAIR ❑ OT ❑ Monitoring Well L7 <br /> DISTANCE TO NEAREST:•SEPTIC TANK SEWER LINES DISPOSA PROP. LINE <br /> FOUNDATION AG LTURE WELL ER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA UCTION SPECIFICATIONS <br /> f Cl Industrial w ❑ Open Bottom it Dia. of Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ c El Tracy Type of Casing Specifications <br /> I'1 Public El Other (; Fl Delta Depth of Grout Seal Type of Grout <br /> r <br /> I I Irrigation ., _Approxi Depth I I-Eastern Surface Seal Installed by <br /> Repair Work Done L7 Type of Pump. H.P. State Work pone <br /> Well Destruction ❑ Well Diameter Sealing Material Depth <br /> Depth fit.- - Filler Material b Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION fNo septic system permitted if public sewer is. <br /> i t available within 200 feet.) ! n <br /> i Installation will serve: Residence��t Commercial_ Other v <br /> Number of living units: Number of bedrooms <br /> jCharacter of soil to a depth of 3 feet:, F Water table depth O <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ i Method of Disposal <br /> Distance to nearest: Well Foundation !Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED 0 Distance]to nearest: Well Foundation Property Line <br /> 1+ ' <br /> SEEPAGE PITS 11 Depth ) Size ' Number <br /> SUMPS LI Distancerio nearest: Well'.., r Foundation Property fine <br /> DISPOSAL PONDS ❑ <br /> 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 <br /> Home owner or licensed agent's signatuie 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 taws of California." °1., <br /> The applicant st ca for all required inspections,Compl to drawing on reverse side. <br /> $ Signed X Title: __ Oug"er_,ii dry�l eI� Date: /1_7 <br /> i FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date ` Area <br /> k �' `� <br /> Pit or Grout Inspection by r Date Final Inspection by ), Data2 <br /> Additional Comments:_ma 4 qvc _.,._..._-- <br /> a ft <br /> i Applicant - Return all copies to: Pian Joaquin County Public Health <br /> Ti Services, Environmental Health Permit/Services <br /> �' 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> l k E AMO�UNT DUE�� AMOUNT REMITTED �K {RECEIVED BY DATE PEERMITt�'i�N'1.O.. <br /> EH 14 �� <br /> �26 <br /> -21(REV.�i n S� <br /> U <br /> FH �l l ,�0 •f ( l �1 - \ •►V„ <br /> �l <br /> t <br /> 1 <br />