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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PIIBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P o BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-ftAT-3q--�z <br /> ,PMIT FMIRES T YEAR PROM PATE ISS <br /> (Complete in Triplicate) <br /> Application is hereby taede,to San Joaquin County for a permit to construct and/or irtatall the vork herein described. This <br /> application in made in eompliarcr: vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health /Services. <br /> � <br /> Job Address ` — '�� �' `� cityC�` �^�Iot Size/Acreage 2 <br /> Owners Name �% / cl,Al-lI Address Phone <br /> Contracto(/�Zdu /"Q� Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ Out of Service Well Ll <br /> PUMP INSTALLATION C SYSTEM REPAIR C OTHER C Mon ging Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP NE <br /> UNDATION AGRICULTURE WELL OTHER WELL TS/SUMPS <br /> INTENDED USE TYPE OF W£L RO8LEM AREA CONSTRUCTION SPECIFICA <br /> In Industrial ❑ Open Bottom ❑ Man Oia. of Weil Excav Dia. of Well Casing <br /> G Domestic/Private ❑ Gravel Pack ❑ Tracy Specifications <br /> M Public FI Other ❑ Oelta Pth of Grout Type of Grout <br /> Cl IrrrJil ^Approx. Depth D Eastern Surface Seal Installed by L_ <br /> Repair Work Done L3 Type of Pump H.P. State Work Done <br /> Welt Destruction D WaN Oiamat Sealing Material & Depth Q, <br /> Depth Filler Material 4 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION C REPAIRIAODITION Q DESTRUCTION G INo septic system permitted it public sewer is <br /> available within 200 feet.) <br /> lnstailation wilt serve: Residenil Commercial_� er <br /> Number of living units: Number of bedr <br /> Character of soil to a depth of 3 feet: C��� - e / Water table depth j <br /> SEPTIC TANK D Type/Mfg _ rlo l /.YY. Capacity L9J- No.Compartments <br /> PKG. TREATMENT PLT.D Method of Disposal <br /> Distance to nearest: Well `��✓ Foundation Property Line <br /> LEACHING LINE _>eNo. &Length of lines 4fr�� Total length size <br /> FILTER BED R Distance to nearest: Well Foundation Property Line Y <br /> int <br /> SEEPAGE PITS I t Depth 2 Size /Number <br /> SUMPS LI Distance to nearest: Walt<7 il_ Foundat+on Prop" Line <br /> DISPOSAL PONDS ❑ <br /> I hereby cartify 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 raguistions 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 r <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 y <br /> certifies the fatlowing:"I cenify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's eompanss- <br /> tion laws of California." i <br /> The applicant must c E aN requi spections. Complete drawing on reverse side. 1 <br /> Signed X-__- Title: �/''? c Date: <br /> OR DEPARTMENT USE ONLY "� J <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection byDate <br /> r <br /> Additbnal Comments: - <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 05201 j <br /> . I <br /> INFO AMOUNT DUE AMOUNT iiEMir CASH RECEIVED BY DATE PERMiEH 13 <br /> YNO. <br /> EM;ale <br /> 24 AW. I <br /> 1 <br />