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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �-- <br /> ENVIRONMENTAL HEALTH DIVISION <br /> I` 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIJ EXPIRES I YEAR FROM DATE ISSUED A <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 /> Job Address � . _._S`�St�►x' a>>� City Lot Size/Acreage <br /> X Owner's Name�� LS`� ��1 Address Pho <br /> Contractor2 -�� Address _ --License No. Phone <br /> TYPE OF WELL/PU NEW WELL ❑ WELL`'REP.LAGEMENT-B- DESTRUCTION 0 Out-,of-Service Nell 0 1 <br /> _.. -._. TE-M- —RE.a.-.._..-. ,i'onitoring Well ❑ <br /> PU LLATION C] SYSTEM REPAIfi D "�""" 'r"07 FIER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. - LINE ! <br /> FOUNDATION A TURE WELL `"" .•0 L PITS/Sf'MPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CO ;i0 P'6FICATIONS 1 <br /> 0 industrial ❑ Open Bottom ❑ Mamec Dia"of Welles tlm Dia. of Well Casing <br /> Ca Domestic/Private C1 Gravel Pack racy Type of Casing Specifications <br /> 1'I Public 1-1Other11 Delta -Depth-of Grout[Seal_ Type of Grout N' <br /> r I fnigauon fff Approx. Depth 11 Eastern i Surface Seal Installed by <br /> Repair Work D Type of Pump H.P. I State Work Done — 3 <br /> Well Destruction ❑ Well Diameter sealing Material & Depth <br /> Depth Filler:Material & Depth A ! <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I_ REPAIR/ADDITION I 1 DESTRUCTION 0a is systempermitted if public sewer is ' <br /> availabI within 200 feetX. <br /> Installation will serve: Residence` Commercial_—_- Other <br /> Number of living units: Number of bedrooms EXF <br /> Character of soil to a depth of 3 feet: N11T,-„ ��� Dr table depth <br /> SEPTIC TANK ❑ Type/Mfg f a acity= '< ! Compartments <br /> PKG. TREATMENT PET. ❑ NBfi-ni Tll�� ve ' U t od of Disposal ' a <br /> Distance to nearest: We k � �l � �pW ne . l <br /> LEACHING LINE Cl No. & Length of lines Lly I*` 4 Tota! lengthlsize <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line t t s <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS CI Distance to nearest: Well i Foundation Property Line <br /> DISPOSAL PONDS ❑ x <br /> i <br /> I hereby certify that I have pared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations o e San Joaquin County <br /> Home owner or lice d agent's signaturp<FTifies the following: "I certify that in the performance of the work for which this Qermit is issued, I shall not <br /> amp! rsa rn such manner as t crime subject to workman's carnpen.w on fav?$-of'Caiifttrtiia7"-'Cori tractor's hiring or sub-contracting signature <br /> cif <br /> the f It ing: 'I cenify that in a ttormancs of the work for which as erniit!a issued, I shall employ persons subject to workman's compensa- + <br /> on laws of ifornia." <br /> Thea lic _- ust call,for,elli- ctiony,_C.orttplete drawing_o .rev. ._side,__. Y- _._.�_�..•, _ <br /> PP XSigned Titl ^' Date: ' wAn <br /> -----r=-•r-- i _ice If <br /> OR DEPARTMENT 115E ONLYT <br /> A lice on Accepted by Date_5 : ��__ Area I <br /> I <br /> It Grout Inspection by Data Final Inspection by Date <br /> Additional Comments: 3 <br /> Applicant - Return all copies to: San Joaquin County Public Health e <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE CK <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE �PERMIT'NO. { <br /> . EN13-24iREV.�inSt l .• `00 <br /> EN t�-26 <br />