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elks ;la n <br /> .S Wte k-A APPLICATION FOR PERM I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> D P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> R <br /> (Complete in Tr plicate) <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 /> Job Address 19;20 �/;tn r �- - - ---..— City` Lot Size/Acreage <br /> �09j/7 Jan �vl'f I Address J � �Dl �l°� Phone O 32-f% �C� <br /> Owner's Name <br /> t ContractorC'`I 'T' C04 -f' ' Address,9!V/ D /�L �".�- License No. Phone <br /> TYPE OF WE UMP: NEW WELL ❑ SWELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INS'T'ALLATION ElT • SYSTEM REPAIR 0 OTHER 0 Monitoring Well C7 <br /> DISTANCE TO NEAREST: SE ANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATI AGRICULTURE WELL OTHER PITS/SUMPS <br /> INTENDED USE TYPE OF WELL P EM AREA CONSTRUCTI CIFICATIONS <br /> Cl Industrial ❑ Open Bottom 0 Martec ell Excavation Dia. of Well Casing <br /> L Domestic/Private Cl Gravel Pack of Casing Specifications <br /> 0 Public la Othe ❑ Delta Depth o ut Seal Type of Grout <br /> GI Irrigation —Approx. Depth Ll Eastern Surface se <br /> Ins d by <br /> Repair Work Done 0 Type of Pump H.P. Work Done_ <br /> Welt Destruction O Well Diameter-- Sealing Material i Depth <br /> Depth Filler Material L Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION In, REPAIR/ADDITION M DESTRUCTION [D iNo septic system permitted if public sewer is <br /> available within 200 fest.) <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: Z Number of b r oms J d, <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ®' Type/Mfg 4 Capacity LZOO No. Compartments <br /> PKG. TREATMENT PLT. Cl 1Method of Disposal <br /> Distance to nearest: Well �_ Foundation J Property Line ZnQ1, <br /> LEACHING LINE 21' No. & Length of lines „� la.d Total length/si:a_ - <br /> FILTER BED n 'Distance to nearest: VVat-_- DD ' Foundation - A~ Property Line . <br /> for <br /> SEEPAGE PITS it Depth Size Number <br /> SUMPS 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 Sen Joaquin County <br /> Home owner or licensed agent's signature cenifies the following: "I certify that in the perlormance 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 /> The applic mus II r at r quire inspebns, Com to drawing on reverse side. <br /> �( <br /> Signed Title: kv/ Date: <br /> DEPARTMENT USE ONLY <br /> Application Accepted by ��ayDate Area <br /> Pit or Grout Inspection by Date final Inspection by Date <br /> Additional Comments: 4 <br /> Air Applicant - Return all copies to: SAN JOAQUIN COUNTY P LIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES M`�✓��t�, <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 65201FEE CK 4 <br /> // \ <br /> INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERM17'NO. LI�� <br /> * Fk t]N[REM, i/nyr <br />