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I APPLICATION FOR PERMIT �,�{ <br /> SAN JOAQU1N COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION11 <br /> P 0 BO% 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> I <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 J ioaquin County Ordinance No. 5k9 and 1862 and the Rules sad Regulations Ban <br /> Joaquin County Public Health Servi ea. <br /> C� � <br /> �`Z'� ��� _t,]tyi/l City � r""1 Lot Size/Acreage 0 <br /> Job Addrsss -7 <br /> c1 J � Address � �V60Phone � �i-4 Z-1 <br /> Owner's Name f ��� <br /> O►L1 r+� �at[.h -1 Pnon� <br /> Contractor ��� Address �! License No.�3�� ���� � <br /> TYPE OF WELL/PUMP: T NEW WELL D WELL REPLACEMENT (1 DESTRUCTION ❑ Out of service bell 0 <br /> PUMP INSTALLATION D <br /> SYSTEM REPAIR C1OTHER O Monitoring well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES - DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> �� <br /> INTENDED USE TYPE OF WELT PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial 0 Open Bottom 0 MSpecifications <br /> anteca Dia, of Well Excavation Dia. of Well Casing <br /> U Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing <br /> II Public Cl Other 0 Dl�Ita Depth of Grout Seal Type of Grout <br />% 0 Irrigation Approx. Depth ❑ Eastern Surface Seut Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Dona <br /> Well Destruction O Wait Diameter Sealing Material & Depth <br /> vzb <br /> Depth <br /> Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRJADDITION 7T DESTRUCTION (No septic system permitted if public sewer is <br /> Iavailable within 200 feet.) <br /> Installation will serve: Residence_.-_ Commercial— Other s <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 fest: Water table depth <br /> SEPTIC TANK C Type/Mfg M Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 I Method of Disposal �I <br /> i ' <br /> l Distance to nearest: I Well Foundation Property Line ' <br /> f � m,. <br /> I <br /> LEACHING LINE ❑ No. & Length of lines Total length/size + <br /> FILTER BED n Distance to nearest: j�Well Foundation Property Line" <br /> SEEPAGE PITS I I Depth M Size Number <br /> SUMPS U Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <br /> I hereby certify that t 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 they flowing: "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 workman's compensation laws of California," Contractor's hiring or sub-contracting signature <br /> certifies the (lowing: "I certify that in the performance'of the work for which this permit is issued, I shall employ persons subject to workman's <br /> compensa-tion lawn of "ornla.' `f <br /> The ap ant ust cal or all required inspections, Complete drawing on reverse side. <br /> Signed f Title: .^_[QA&l Data: F <br /> 17PAIRITMENT USE ONLY <br /> i Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by - Date <br /> Additional Comments - <br /> Applicant - Return all copies to: SAN JOAQU�IN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N BAN JOAQUIN, P O BOX 2008, STOCKTON, CA 65201 <br /> k <br /> IFEE <br /> NFO AMOUNT DUE A UNT REMITTED CASH RECEIVE) BY DATE PERMIT NO. <br /> I ►�, II <br /> . EH13.241FleV.»K5i tvU t� ��� <br /> EH t{.le <br />