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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIROMI(ENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERM[ T EgPIRES 3 <br /> !EAR FROM DATB 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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban <br /> Joaquin County Public Health Service . <br /> Job Address City A Lot Size/Acreage /� ac,."4 . <br /> Owner's Name , ` "` t ' <br /> .,Address� V i t.� Phone <br /> Contractor Address License No. X <br /> j <br /> T Phone -0 / <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well D <br /> y PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPO AL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL HER WELL PITS/SUMPS I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTR N SPECIFICATIONS + �7 <br /> C7 Industrial' ❑ Open Bottom ❑ M_ant_eca Dia. all xcavation Oia. of Well Casing V <br /> ❑ Domestic/Private ❑ Gravel Pack ,C] Tracy�� yype of Ca _ — . ' UJ <br /> Specifications <br /> !'I Public f 1 Other # f7 Delta Depth of . out Seal Type of grout 3 ~� <br /> I ! Irrigation _Approx. Depth � I I Eastern y,Surface Ssul Installed try � U' <br /> Repair Work:Done ❑ Type of Pum t rf. .I 1 <br /> p H.P. State Work Done <br /> Well Destruction ❑ WeN Diameter t3ealing Material i Depth <br /> t <br /> i Depth ' Filler�Material i"Depth 'i # <br /> 'TYPE OF SEPTIC WORK: NEW INSTALLA ON REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sower is <br /> T. available within 200 Ieet.M <br /> Installation will serve: Residence Commercial_ ther <br /> Number of living units: Number of bedrooms 1 <br /> Character of soil to■depth of 3 feat: r f Waterbldepth I { <br /> SEPTIC TANtae e <br /> K. ❑ Typo/Mfg t <br /> No. Compartments <br /> ' <br /> PKG. TREATMENT PLT.❑' Cpacity NoComartment � <br /> r* Di <br /> Method o <br /> Distance to nearest: Well,��oundetien� property Line_�� <br /> t <br /> LEACHING LINE C1 No. 8 Length of linea <br /> I t length/size <br /> FILTER BED0 Distance to'nearest: Well i) U <br /> j i I oundation <br /> Property Lina <br /> SEEPAGE Pi75 I I Depth Size umber <br /> k ._.. I <br /> SUMPS t;l Distance to rut: Well oundation ' <br /> DISPOSAL PONDS Property Line I <br /> 1 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 /> eines and regulatiorn of the San Joaquiri'County I <br /> Home owner or licensed agent's signature certifies the following: � r <br /> "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 become subject to WoPkman's compensation laws of California."-Contractor's hiring or subcontracting 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 4alifornia." <br /> Thea t �._ ! <br /> pelta cell fpr required nrpections. Complete dia'wing on reverse side. y <br /> Signed ! <br /> Title: i <br /> Date: <br /> F DEPARTMENT USE ONLY <br /> Application Accepted by # a� r Q t <br /> j Date ~1 Z' Area b Z + <br /> Pit or Grout l ` <br /> Inspection by Date Final Inspection by <br /> �k � Date <br /> Additional Comments: ` <br /> A R � <br /> Applicant - Return all copies to: .!,San Joaquin County Public Health Services ; <br /> i' Snviroamental-Health Permit/Services <br /> A 445 N San Joaquin,' P O Bou 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK i <br /> INFO CASH RECEIVED BY DATE PERMIT'NO. <br /> (� �y # <br />. EN 13•H IIIEY.t i M Sr [ I , D� / �Z <br /> EH 14-at to <br />