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APPLICATION FOR PERMIT j <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL BEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)466-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PIMMIT EXPIRES T YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby nestle,to Hem Joaquin County for a permit to construct and/or install the work herein deed• <br /> application Is made in COUVIlance with Han Joaquin County Ordinance No. 5k9 62 and the Rules and Regulations of San <br /> Joaquin County Public Health Service . <br /> I! J a <br /> Job Address tat Site/Acreage <br /> I (� .. E„t City <br /> Phorw <br /> �.J <br /> I( Owrror'a NeNam �.t Address <br /> p i <br /> Contracts Address <br /> 6 J icense No. o S ft Phone <br /> I TYPE OF WELL/PUMP: NEW WELL ❑ WELL R LACEMENT't7,, DESTRUCTION'❑ Out.MoService Well Ll <br /> nitoring Well 0 <br /> PUMP INSTALLATION ❑ S TEM REPAIR43' OTHER O <br /> DISTANCE TO NEAREST: SEPTIC TANK WER LI DISPOSAL-FLD. PROP.4LINE <br /> , <br /> FL� UNCATION_ A ICU URE WELL OT�I�R.WELL PITS/SUMPS ._ <br /> INTENDED USE rTVPE OF WELL PROBLEM FA CONSTRUCTION SPECIFICATIONS [ <br /> O:Open-Botion, O Mant a Dia. of Well Excavation Die. 01 Well Casing <br /> 0 Industrial _ <br /> Type of Cosin Specifications <br /> ❑ Domestic/Private C1'GraveFPei "SO T 9 <br /> I'1 Public I�ther �( Its Depth of Gmutbeal. , J Type of Grout <br /> 4 1 +led 1 <br /> I I Irrigation ApprcIx. Depth I I �aatem Surface Seal;Instilled by - �1 <br /> Repair Work Oona 0 T ae•of-Sump H.P. Srots'�Jork;tSoI <br /> + I Seall Material &•Depth,, L ! V <br /> Wel!Destruction 0 Well Diameter 1 <br /> Depth --~ tiller urisl & Depth t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIOJ REPAIRIADDITION I I DESTRUCTION 7 INOave septic with in <br /> 2 permitted it public anwer is <br /> 1 yI <br /> � <br /> available within 200 feat.l <br /> Installation vAll serve: Residence t Commer,w Other ``� <br /> I -�.{� 1 <br /> Number of living unite _ Number of betlroom_�.G,f_ __1- <br /> t Character of WH t a depth of 3 feet: .� ��l �t d Water ebb peDih <br /> + t eF r ?.I) ".'-'—No.impartments \ <br /> SEPTIC TANK: ❑ Typs/Mfg l Ga?e,ch �/ <br /> / ';v /' �Mlethod of Dispose <br /> \PKG&TREATMENT.PS0 i �Q ®�7L <br /> Distanceto nearest: Well ! Foundation Line <br /> LEACHING LINE �J ❑ No.6 Lingth of lines' ! pull lengthlsixe <br /> Li <br /> FILTER BED 0 Distance to nearest: /vVljall Foun atwri-- Property Lino <br /> SEEPAGE PITS I I Depth ! Sin y' Nu r <br /> SUMPS Cl Olstanrq to est: WellFounBation Property Line <br /> ` DISPOSAL PONDS ❑ <br /> I hereby unify that I have prepared this application inti that the.work will be done in accordance with San Joaquin county ordinances,state laws, and <br /> I rube end tag lotions of the San Joaquin County � t 71! <br /> Home owner or licensed agent's signature certifies the fo owing: :9 certify that in the performance of the work for which this permit is issued.I shall hot <br /> `{I employ any person In such manner as;on become tubjeci�io'Workman's compensation aws of California."Contractor's hiring or subcontracting signature <br /> certifies the following:"I c�rdly that in the peAormence of the work for which this permit is issued,1 eMll employ parsons subject to workman's comwnsa <br /> i tion laws of California." <br /> 1 The spplic must r al!!17equir ll inspections. Complete drawing on rererae side. <br /> {i <br /> Signed Title: Date: <br /> 12-2 -clJ <br /> FOR DEPARTMENT USE ONLY <br /> 1 - ' <br /> Application Accepted by !:r Date Area,�1 <br /> Ph w Grout Inspection by t Date Final Inspection by �i.e>""'� Date <br /> + 1 f <br /> i Additional Comments: <br /> Applicant - Return ell copies to: Hep Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. ffaseltoo Ave., P 0 Box 2009, Stockton, CA 95201 <br /> t(j NO AMOUNT DUE AMOUNT REMITTED CK 8 CASH RECEIVED By DATE PERMIT NO. { <br /> 1 EH 1124utEV.11^51 ..//_! .°� /f!„oe� q�7 _.--..e—•/ - '° X 3360_.r_.._..4._.-t <br />