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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> NOENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE.. , PHONE (209)468-3420 {fJ <br /> P O BOX 2009, STOCKTON, CA 95201 2eG�W oa� <br /> n>RR>v11 EXPIRES 1 YEAR FROM DATE IPSUEP <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 F <br /> Joaquin County Public Health Services. -,,J i <br /> Cityr-//W1)Lot Size/Acreage y <br /> Job Address 1 <br /> J� Owner's Name <br /> Oe. p ! Address A0 Phone <br /> i' ContractorAddress d License No.akvs-FIL Phone L <br /> a <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well <br /> Monitoring Well ❑ <br /> UMP INSTALLATION ❑ SYSTEM REPAIR ❑ OT ❑ ) <br /> DISTANCE TO NEAREST: SEP K SEWER LINESOISPO PROP. LINE i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBL ONSTRUCTION SPECIFICATIONS 1 <br /> L-1 Industrial ❑ Open Bottom teca of Well Excavation Dia. of Well Casing <br /> D Domesticl Private ❑ Gravel Pac D Tracy Type o ing— Specifications <br /> Il Public [I Ot n Delta Depth of Grout Type of Grout <br /> I I Irrigation —.Approx. Depth ' I I Eastern Surface Seal Installed by <br /> Repair Work Do —Type of Pump H.P. State Work a <br /> " <br /> Wel! Destru ron ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( I DESTRUCTION I INo septic system permitted it public sewer is <br /> %available within 200 feet.) <br /> Installation will serve: Residence__Y._ Commercial_ Other <br /> - 0 <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal. <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED [_7 Distance to nearest. Well Foundation Property Line <br /> s <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS L# Distance to nearest: _ Well Foundation Property Line a <br /> DISPOSAL PONDS ❑ <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 /> 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 become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting 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 California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. t <br /> Signed >._ Title: _- 4��1�J4C: I ._ Date: <br /> liv I <br /> FO DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> o Pit or Grout Inspection by Date Final Inspection'by Dates <br /> Additional Comments: OK A... <br /> Applicant – Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> s 1601 E. Hazelton Ave., F 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> . EH 13-24IREV.iixINFO -nai <br /> EH 14.2E <br />