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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> �® 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT_ EXPIRES 1 YEAR FR�ATE ISSUED <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 campliance with San onqui County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 22- `7 - City IAA ., "n Lot Size/Acreage <br /> Owner's Name v Address Phone <br /> i <br /> Conti act ` "�P Address' ' - ,License No. Phone I <br /> f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ ,� DESTRUCTION ❑ Out of Service well ❑ t <br /> Tt PUMP INSTALLATION O SYSTE REPAIR ❑ OTHER p Monitoring Melt ❑ i. <br /> r <br /> i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE `DISPOSAL FLD. PROP. LINE F <br /> i! FOUNDATION AGRIC URE WELL OTHER WELL '� PITS/SUMPS �. <br /> INTENDED USE TYPE OF WELL PROBLE A CONSTRUCTION SPECIFICATIONS <br /> If ❑ Industrial ❑ Open Bottom ❑ tees , Dia. of Well-Excavation Dia. otl.Well Casing <br /> t-1 Domestic/Private ❑ Gravel Pack racy rj iType of Casing - Specifications I <br /> Il Public C7 Other n Delta Depth of Grout Seat: Type of Grout <br /> I I Irrigation _.Appfox. Dep I I Eastern Surface Seat Installed-by <br /> Repair Work Done 0 Type of Pump P. State,Work'Dons _ " <br /> f4 Well Destruction ❑ Well Diameter sling lia�ezi`af i=Aepth l <br /> I,t Depth t Filler Material R Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIRIADDITION I I ,DESTRUCTION I 1 INo septic system permitted i1 public sewer is {� <br /> / 3" available within 200 feet.) <br /> " Installation will serve: Residence_ Commercial Other <br /> Number of living units: "Number of bedrooms^ <br /> 4 <br /> Character of soil to a depth of 3 feet: a 02 Water table depth <br /> .SEPTIC TANK. ❑ Type/Mfg � ' Ca No. Compartments� <br /> PKG. TREATMENT PLT, Ll : Method f D' sal J� <br /> Distance to nearest: Well `� *o,ndation J�� Property Lin <br /> {I f i <br /> k <br /> LEACHING LINE ❑ No. 8 Length of lines gul Tote! gth/size i <br /> ft- <br /> FILTER BED C 1 Distance to nearest: Well Foundation Property Line ' <br /> k <br /> SEEPAGE PITS It Depth Sire Number , <br /> Otte- <br /> SUMPS 0 Distance to est: Well IVY Foundation Property Linoi <br /> DISPOSAL PONDS —❑. (� <br /> j: I hereby certify that I have prepired this application and that the work will be done in ace rdance with San Joaquin county ordinances, ata and <br /> i rules and regulations of the San Joaquin; County / <br /> Home owner or licensed agent's signature cortifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not 11 <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature I <br /> certifies the following: "I unify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compenss- I <br /> tion laws of California." 1 <br /> {l The applicant at call 1 r aired ins tions. Complete drawing on reverse side. rf s <br /> t � r Date: <br /> Signed title: � 1 <br /> FOR DEPARTMENT USE ONLY t `� <br /> ,; A Ica Accepted by Date y 1 �' Area 01-X <br /> Pit Grout inspection b Date Final Inspection by � "- Data ) <br /> i Additional Comments: t <br /> .j <br /> Applicant - Return all copies to: Ban Joaquin County Public Health Services <br /> Environmental Health Permit/Servicesy <br /> 445 N San Joaqula ox 2009, Stkn, CA 95201 <br /> t <br /> I� <br /> r INF AM NT DUE /AMO t REMf7TED K WED BY DYE PERMIT NO. <br /> • Ex 1 �-/ <br /> 5-74(REV.11 K a! /l , t/� E <br /> EH 114.M 111 Ov <br />