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APPLICATION FOR PERMIT
<br /> SAN JOAQUIN COUNTY PUBIIC HEALTH SERVICES
<br /> ENVIRONMENTAL HEALTH,DIVISION
<br /> 1601 F. HAZELT014'AVE.-,- PH6NE' (209)468-3420
<br /> P O BOX `2009,=1STOCKTON,;u`-CA'' :9`5'2G ,rIr r tSC>T ,' ,r,',rr: I•,
<br /> it 'lilt) (4P(_,0 1n6 ; ,_.:)i '„`
<br /> C
<br /> RERMI-7—EXPIRES-1)`YEAR fFROM�D'ATB .12SUED`;,� � s�if."Jc)� :, ,>. :., , • .,C
<br /> (Complete in Triplicate)
<br /> Application is hereby made to San Joaquin County for a+permit to'construct'atiii%or"install'the work herein described. This
<br /> application is made In:compliance with' San,_Joaquin�-Coi!rify7.Ordiba`{nceC`Nityd°.rr 5A9,°`1a"iid'1662}3Y,iin,d• :tliiy'R'=u,lIecsy"-a•iivd: R�e,
<br /> gulations of San
<br /> Joaquin County Public Health. ts, LtSizeAreageJob Address
<br /> 70
<br /> t t
<br /> Owner's Name = t °Address_, 1-
<br /> Contractor Address �� """ " Llcer:"se NoVaS Phony
<br /> TYPE OF WELL/PUMP: .NEW ELL,'O,- .te _ WELL•REPLACEMENT_C.1... _,,,,__A9STRUCTION, ❑ Out of, Service Well Cl
<br /> PUMP INSTALLATION ❑. SYSTEM REPAIR OTHER ❑ Monitoring Well
<br /> DISTANCE TO NEAREST: SEPTIC TANK SEWE 'LINES" "�DISPOSA-L FCD-. - " ..-- -PROP.-LINE
<br /> FOUNDATION. AGRI ULTUR „-LL OTHER,.WELL PITS/SUMPS
<br /> INTENDED USE TYPE OF.WELL PROBLEM A CONSTRUCTION SPECIFICATIONS
<br /> ❑ Industrial ❑ Open Bottom' -�❑ Ma ca ! Dia: of Well Excavation 1 i ' Dia: of Well Casing
<br /> C
<br /> Domestic/Private 0-Gravel Pack---.- <1F
<br /> r - 7 g I"1 Public C7 Other Depth of Grout Seal Type of Grout
<br /> I I Irritation ,.,�,•.Approx. pthrn ' Surface Seal installed byw_s
<br /> Repair Work Done f-I - Type-of-Pur»P
<br /> r _
<br /> P -- -
<br /> all n$ Materiel & Depth I7
<br /> i
<br /> Well Destruction 0 Well Diameter
<br /> I
<br /> Depth W ry f Slier IMaterial8'-Depth
<br /> TYRE OF SEPTIC WORK:-•-NEW iNSTALIATION I l flfF!AIR!ADDITIONRLi67ION-(-I a•sept'a-system permitled-ilpublic-stwer is- ?"
<br /> i ailabl within 200 feet,) I
<br /> Installation will serve:' Residence_'Commercial T Oth'et " `-
<br /> Number of living units: Number of bedrooms
<br /> Character of soil to a depth of 3 feet'. _ — WAier tab depth 1 I '
<br /> :
<br /> SEPTIC TANK _ yy ...... NWE CUnpailrUL.n._t_s,�..�.
<br /> s
<br /> PKG. TREATMENT PLT. ❑
<br /> _.._'_Method af-Disposat.
<br /> Distance to nearest
<br /> Well )ondafi I Property Line
<br /> LEACHING LINE 0 No a th of lines ! Totaf_length/size-
<br /> Long
<br /> _ i ;
<br /> FILTER BED Cl Distance to nearest Wall Fo ndation Property Line
<br /> SEEPAGE PITS I I Depth I Si:e N,umbe_r
<br /> _ —t_
<br /> SUMPS LI Distance to nearest: !W - Foundation' Property Ljne
<br /> DISPO
<br /> AL
<br /> II hereby certify hthhat I havO prepared this app Hcaton a d that thew k will{be done.n accori�anca_wi h_S�an.Joa uin.county.ordinances-stat - �
<br /> Y Y P _ qa-laws,-and ?
<br /> rules and regulations of Itha San Joaguln County ;
<br /> Homo owner or licensed agent's signature certifies the following;"I_certify•that in the performanceoj the work for_which!this, parmit.,is.issued;_tsh'all_not
<br /> employ any person in such manner,as to become subject to workman's compensation lawsiof CaPir'ia." Contractat's hiring or subcontracting signature
<br /> certifies the following: "I certify that_in_the_peitornia _. of the work for which.ihis permit is F8sued I sFiall,ernploy persons subject.to•workr4tan's compensa - --
<br /> tion iaws of California." j
<br /> i
<br /> The applicant usstt call-f0 Pre qui i ospections. Complete drawing on-reverse-side. -a_ g-- j-- ; - <,-
<br /> Signed X # - --Title Date:-*-A'-=:!2--E6/
<br /> r_.. OR. P_AR7R4ENT-USE.0NLY
<br /> 1 i I p� I I
<br /> Application Accepted'by ' I _Date.- I 1 �. .Area - a
<br /> Pit or Grout Inspection by FihaUris.pection.by. � � - -'-_Date�� -��/�•��
<br /> Additional Comments. i
<br /> Applicant - Return all Copies to: San Joaquin County, Public Health
<br /> �._.... 1601 E. Plazelton Ave_ PJ01Box!2009, Stockton, tCAV 195201 mMl .M,...�ry
<br /> + r -Services Envirant¢ental Health'Permi't SAyyd88
<br /> FEE
<br /> INFO AMOUNT bUE i AMOUNT RWITTED ? CASH ! !CK V RECEIVEp BY ' i DATE; PEF41'N6W ! I
<br /> ,'
<br /> EH 13.24 1REY.fray) ` l_., L _1 ._i. I._ _ !
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<br /> EH t4-Ie —•----
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