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i <br /> I <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � r <br /> ENVIRONMENTAL HEALTH DIVISION ,� <br /> P O BOX 2009, STOCKTON, CA 95201 ^"° <br /> (209) 466-3447 <br /> (Complete in Triplicate) <br /> Application is hereby made'to Sao Jaaquio County for a permit to construct and/or install the work herein described. This <br /> application is made in eo4liance Vith San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations or Sao <br /> Joaquin Cpuaty P blicH 8ervice4. f <br /> es <br /> /! -lam e [ 10 City Lot size/Acreage <br /> r¢EY <br /> Job Address <br /> g611!� Address a .OGZ -�P/�oA� Phone N I <br /> Owttar s Name n r7 <br /> CIAO !'tcv►. it Address � e r IfI4,2 ' License No. Phone <br /> Contraclw I <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION Q Cut of Service Well O <br /> ' SYSTEa RiPAIA O OTHER O monitoring well O <br /> PUMP INSTALLATION� � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER'LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL..r__ PITS/SUMPS <br /> ' INTENDED USE _TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS re <br /> n Industrial ❑ Open Bottom C3Menteca Die. of Well Excavation Dia. of Well Casing <br /> WOomeseic 1 Private <br /> 1i Gravel Pack Type of.Casinq G Specifications <br /> Q Public CI Other Cl E?alta of Grout Type o1 Grout <br /> CI Ifrigation pprox. Depth O Eastern Surface S Installed N <br /> Repair Work Dons 0 Ype of Pump � H.P. tate Work Dona <br /> Well Destruction Well Diameter <br /> 6r. "Sealing Material i �1 <br /> 08RtF � -Filler material i h <br /> TYPE oP SEPTIC RK: NEW•INSTALLATION 0 REPAIAIADOITIO ESTRUCTION G (No septic system permitted it public sewar is <br /> available within 200 lost.) <br /> Installation will serve: _; Other <br /> Number of living units: Number of bedrooms <br /> Character of soh to a depth of 9 fast: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.C1 Method of Disposal <br /> Distance to nearest: WSIi• Foundation Property Line <br /> LEACHING LINE Cl No,A Length of linea Total length/sira <br /> FILTER BED CI Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sue ! — Number <br /> l SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ A � <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 sgsnt's signature canities 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 workmen's compensation laws of California."Contractor's hiring or eutYcontrscting signature <br /> eertiflas 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 compenss <br /> an laws of California." <br /> The applicant must tail for all required'ins Rclions. Complete drawing on reverse side: q <br /> 4 Signed _ Tills: <br /> Sulr5 4 r V Ltd Date: /0" <br /> 1 FOR DEPA SE:0IVLY -. <br /> Application Accepted by I 1 ' Date t) Arae <br /> Pit or Grout Inspection by Date Final Inspection b <br /> Do <br /> Additional Commems: — <br /> Applicant - Return all copies to: SAN JOAQUIN COMM PUBLIC HEALTH SERVICES <br /> II ENVISONV$NTAL HEALTH DIVISION PSRNIT/SERVICES <br /> 445 H SAN JOAQUIN, P O SOX 2008, STOCKTON, CA 86901 <br /> fEE OUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO I <br /> CASH .ry qn C <br /> 4 4M 7{•� <br />