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{ <br /> APPLICATION FOR PERMIT> <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 11601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> W"IT EXPIRES 1 YTAR FROM PATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby rsade,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 (/l ,® 3a �, � /@ 8 <br /> w. _ City of Size/Acres e <br /> I Owner's Name /}.C.i.c j 0-tJJ Address �"`�— �� Phone <br /> fi C 0r Yi_ Address L e ��} � License No.:2 Phone - <br /> TYPE OF'W MP: NEW WELL ❑ -WELL.REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> P IN5TALLATION ❑� SYSTEM REPAIR C1Y Y OTHER ❑ t4oriitoring"Well C7 <br /> DISTANCE TO NEAREST:-SEPT1C_y4 OP. LI <br /> K SEWER LINES DISPOSAL FLD. NE <br /> I FOUNDATION AGRICULTURE WELL OT PITS/SUMPS <br /> INTENDED USE TYPE OF WELL 1 PROS EA ,CONS N SPECIFICATIONS <br /> f n Industrial ❑ Open Botiom r ❑ Mantec ia. of Well Excavation Dia. of Well Casing <br /> ' Ll Domestic/Private El Gravel Pack racy Type of C-ftincl Specifications <br /> I'I'Public f-7 Oihe r 1 n Deltas 4 Depth"o"f Grout Sea Type of Grout € <br /> f I I�Imilation ' _.Approx Depth I I Eastern Surface Seal Installed by <br /> Is <br /> Repair War a 13 Type of Pump H.P. State Work Dan t <br /> estruction ❑ Well Diamettir Sealing Material & Depth { <br /> Depth <br /> II ff <br /> l <br /> - 4 i Filer Naterisl & Depth <br /> r � t p , <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION^ fNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence! Commercial " 0 or <br /> Number of living unit ''a" b f edr s <br /> E L <br /> Character of soil to a epth of .j Water table depth <br /> / � P <br /> `SEPTIC TANK to Type/.Mf git d Capacity No. Compartments 0 <br /> PKG. TREATMENT PLT. ❑PerMit 9 have <br /> �.r y Method of Disposal i <br /> W0Thtt0jtt9 <br /> nftMP10t ll_ n5 A 8ddation Property Line t <br /> 1 f LEACHING LINE ❑ or& ng h` lines !jeep Total length/size K f <br /> FILTER BED 0 Distance to nearest: Well Foundation~"� Property Line <br /> 1 SEEPAGE PITS I I Depth Size Number f <br /> SUMPS LI Distance to nearest: Wel? Foundation_ -___ Property Line <br /> DISPOSAL PONDS ❑ IV <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 following: "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 became subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in 1he performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." ° x <br /> The applicant must call for all required inspections. Complete drawing on reverse.side. <br /> Signed X Title:— &-c-.0 1" Date: <br /> I <br /> F FOR DEPARTMENT USE ONLY <br /> Lr Application Accepted b \ i <br /> PP D Y Date Area <br /> Pit or Grout Inspection by Date Final Inspection by I Date <br /> Additional Comments: <br /> Applicant - Return all copies to:I San Joaquin County Public Health <br /> 1`Services, mviroawntal Health Permit/Services <br /> 1601 E. Hazelton Ave.. P 0 Box 2009, Stockton,CA, 95201 r <br /> INFO AMOUNT DUE � AMOUNT REMITTED CK 4RECEIVED BYE. DATE PERMIT'NO. <br /> Ci1SH <br /> + EH1324 IREVH 1 SO.t i x 5F <br /> _.QC�_ ry <br />