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APPLICATION FOR PERMIT II <br /> �I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201. � <br /> PFMIT EXPIRES 1 YEAR FROM DA ED <br /> I (Complete in Triplicate) <br /> Application is hereby made.to <br /> ecnpli Joaquin count for a permit to construct and/or install the work herein de ibed. Th <br /> San Joao Y <br /> application is made in e¢npliance with San Joaquin County Ordinance No. 51+9 a d IA62 and the Rules and Regulations of San <br /> Joaquin County Public Health Service . <br /> . City Lot Site/Acreage <br /> Jab Address C. <br /> i E ,�. <br /> .�' •'� ~'•. f? � Address Phone <br /> Owner's Name - -" <br /> Phone <br /> Contractor Address <br /> TYPE OF WELL/PUMP: NEW.WELL ❑ WELL R LACEMENT`[7- DESTRUCTION"❑ put,of Service Well ❑ <br /> r S STEM REPAIR-L� ".l, <br /> OTHER ❑ Monitoring Well ❑ <br /> PUMP INSTALLATION ❑ <br /> WER LI DISPOSAL FLD. <br /> PROP"LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK l <br /> FOUNDATION- A ICU URE WELL OT'AER,WELL ,PITS/SUMPS _ t <br /> INTENDED USE <br /> TYPE OF WELL PROBLEM EA CONSTRUCTION SPECIFICATIONS t i <br /> 0,Open ❑ Mant a Dia. of Well Excavation Dia. of Well Casing <br /> C} industrial , . <br /> Type of Casing Specifications <br /> Cl Domestic!Private LI;Gravel'Pack ❑ T cy , <br /> I'1 Public I-1 Other �3 elta Depth of Grout,,Seal ' Type of Grout <br /> 11 Irrigation .Approx. Depth I 1 Eastern Suriace SealInstalled <br /> t Repair Work Done 0 Type-of..P_ump H•P• 5[atef,Work",one ` t <br /> Well Destruction ❑ Well Diameter <br /> I <br /> Seali Material &•Depth, <br /> Filler terial & Aepth <br /> Depth <br /> i I <br /> t TYPE OF SEPTIC WORK: NEW INSTALLATI� <br /> REPAIR I I DESTRUCTION 1 I,availablerc s�slem writhin 200 feet.)itted it public sewer is + <br /> ¢ r + 1 <br /> I <br /> installation serve: Residence� Commercial Other + �► ` <br /> I 4 .t .t, v , I <br /> Number of living units: Number of b_edrooms <br /> t Character of soil to a depth of 3 feet: 1 - Watetable,depth <br /> r air 1111 r Capacity`-No. mpartments l <br /> f SEPTIC TANK. A ❑ Type/Mfg t L \ <br /> •;v:vt �„i' L�'�� i� }.,. Method of Dispose <br /> -,FKG1TREATMENT PLT. ❑ ? T T <br /> Distance to nearest: Well! on Property Line <br /> t r <br /> LEACHING LINE I .J ❑ No. & Length of lines, �" - otaf length/size <br /> ' ` ' 1 s Faun ation� Property Line <br /> FILTER BED ❑ Distance to nearest: Well G 1— <br /> y. k 3 I 0 <br /> SEEPAGE PITS 11 Depth Sire Nu ber <br /> SUMPS 0 Distance to nea est: Well 'Foundation_ Property Line <br /> k ° <br /> DISPOSAL PONDS ❑ -1 r <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 -. <br /> Home owner or licensed agent's signature certifies the Idi owing: "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 subjeci io"workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I cert\ify that in the performance of the woFk for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." ! � I/ <br /> i The applic must c r all(equip Y,Inspections. Complete drawing on reverse side. <br /> Signed Title: <br /> Date: 12--2 <br /> A ?+- FOR DEPARTMENT USE ONLY <br /> y// <br /> Application Accepted by Date Area q <br /> Pit or Grout Inspection by Date <br /> Final inspection b Date ` <br /> Additional Comments: <br /> r <br /> Applicant - Return all copies to: Ban Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> S 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT aUE AMOUNT REMITTED CASH RECEIVEV My DATE PERMIT'NO. <br /> INFO <br /> i EM 13.24 IREV.1/n 6i �/ _ <br />