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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE, , PHONE (209)4685420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FRQM DATE ISSUEP <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 <br /> Joaquin County Public Health Services. <br /> Job Address `� (�"(��t� City of Size/Acreage <br /> X Owner's Name 0.� � \1 �L ��y, — Address PhoneZ "�1 <br /> Contractors Address _ License No. " Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C_l DESTRUCTION D out of Service Well ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER Monitoring Well <br /> DISTANCE TON : SEPTIC TANK SEWER LINES DISPOSAL F PROP. LINE <br /> FO ON AGRICULTURE WELL ELL PITS/SUMPS _ f <br /> INTENDED USE TYPE OF WELL BLEM AREA CTION SPECIFICATIONS <br /> Cl Industrial 0 Open Bottom D Man Dia. of Well Excavation Dia. of Well Casing <br /> to Domestic/Private ❑ Gravel Pack racy Typ sing Specilications <br /> 001 <br /> I"1 Public Cl Other n Delta Depth of Grout Type of Grout <br /> — <br /> i I Irrigation Approx. Depth I i Eastern Surface Seal Installed by +� <br /> Repair Work Do Type of Pump H.P. State Work Done <br /> Well D tion ❑ Well Diameter Sealing Material & Depth <br /> 1-0 Depth Filler Material fi Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I f DESTRUCTIONNI lNo septic system permitted if public sewer is <br /> available within 200 feet.1 <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units; Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <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, l 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, t shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicaylinust call for all required inspections. Complete drawing on reverse side. <br /> (Signed - Title: 4 Aaalic Date: <br /> DEPARTMENT USE ONLY r <br /> Application Accepted by ILDate Area �— <br /> Pit or Grout Inspection by Date Final Inspection byDate' <br /> Additional Comments: <br /> Applicant - Return all. copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH K I RECELVED BY /f DATE o P�EHMiIT''NO. <br /> • EH 13-241AEV.siw5i O`-' [ n !I 1 1`-1 L3 <br /> EH 14.26 �`44„II {{i..... // t <br />