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APPLICATION FOR PERMIT <br /> Y SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 20091 STOCKTON , CA 95201 <br /> (209) 468-344-7 <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. Thia <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 " the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address r �n City Lot Size/Acreage 9 G.G/',C.. <br /> Owner a Nerve <br /> �I�tt/� I / U Address �U ���- Phone)' r5 G(Z'F' <br /> n tr — 5-7 <br /> f,� /] l} Up 33 V i S License two y�16 9 Phone 7a 3714_9 <br /> COI1trdClt7r�U'��`~�� Vii r� Address <br /> TYPE OF WELL/PUMP WELL k WELL REPLACEMENT rl DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP MSTALLAT1104 ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well or, <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLO PROP LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> t <br /> INTENDED USE TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Minteca Ore of Well Excavation Dia of Well Casing <br /> '� U G <br /> U Domestic/Private ❑ Gravel Pack C"] Tracy Typd of Casrng Specifications <br /> C} Niblrc -�Qther S�,„r) ❑ Delta Depth of Grout Seal ' Type of Grout <br /> Cl irtrUation /5; Apwox Depth ❑ Eastern Surfico Seel Installed by <br />`kr Repair Work Done U Type of Pump H P State Work Dona <br /> r T� Will Destruction O Wail Diameter Sealing Material i Depth <br /> in Depth Piller Material L Depth <br /> TYPE OF SEPTIC WORK NEW INSTALLATION 17 REPAIRIAOOITION C1 DESTRUCTION CJ (No septic system permitted if ptrbirc sewer rs <br /> available within 200 feet I <br /> Installation wtil servo Reardened — Commercial — Other <br /> Number of living unrlu Numbor of bedrooms <br /> Character of rlod to a depth of 3 fear Water table depth <br /> SEPTIC TANK ❑ TypoiMfq Capacity No Compartments <br /> PKG TREATMENT PLT C] Method of Disposal <br /> 011asnce to nearest Well Foundation Property Line <br /> LEACHING LINE 0 No 6 Length of line$ Total length/size <br /> FILTER BED 11 Distance to nearest Well Foundation Property Lina <br /> SEEPAGE PITS 11 Death Size Number <br /> SUMPS LI Distance to nearest Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I hove prepared this apaiicstion 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'i signaturd camfiet the following t canify that in the performance of the work for which thrs permit is issued I shall not <br /> employ any person in such manner as to become subject to workmen s compensation laws of California Contractors hiring or sub•controcting signature <br /> certifies the following I csrhfy that on the performance of the work for which this permit is issued I shall employ persona subject to workman s compenso- <br /> lion laws of California ' <br /> Thi ipplicint must a tot idl agwrbd i spections Complete drawing on reverse side <br /> f Date <br /> i 6IZ� <br /> Signed Title � l - <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> r Data o2' 13- Area <br /> Pit or Grout Inspection by ate Final Inspection by Date <br /> llaitional Comments <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 448 N SAN JOAQUIN, P O BOX 2009, S'IWXTON, CA 93201 <br /> FEE INFO AMOU�NrT^OUE AMOUNT REM11TE0 CASH RECEIVED BY DATE PERMIT NO <br /> fro 13 24 4"EV 1i w 6r •ter• ��. „ t��3 f /���-y y �o �q�1 <br /> 40 — —— — <br />