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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERV1_C S_J <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STMKTON, CA 95201 <br /> (209) 468-3447 <br /> PERMIT EXPIRES I YEAR PROM DATE ISSUED <br /> (Complete is Triplicate) <br /> Application is hereby made,to Sam 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 1842 and the Rules.and Regulations of San <br /> Joaquin County`Public Health Services. [/� f <br /> 'ob Address ✓ t/�/ f� Qom' SNI City Lot Size/Acreage <br /> c <br /> Ownx's NamJ�-� /,J //4r'V� Address 'Y �Qly—� i Phone <br /> n <br /> Name C/ <br /> �ontraclof 29e `roG/ AddressC� /License <br /> License No 1 hone 3 j `� <br /> TYPE Of WELL/PUMP, NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 7 Out of SirVece Will ❑ <br /> PUMP ALLATION ❑ SYSTEM REPAIR ❑ OTHER Loring Well C1 <br /> DISTANCE 70 NEAREST: SEPTIC TAN SEWER LINES" -^'_ ' VISPOS' - - -PROP. LINE <br /> FOUNDATION Y AGRICULTURE WELL HCR WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELD+ PROBLEM A RUCTION SPECIFICATIONS <br /> Cl Industrial ❑ Open Bottom ❑ Man D Weil Excavation Dia. of Well Casing <br /> r U Domestic IPrivate 0 Gravel Pack _ racy Type of Cas Specifications <br /> iM. Public f'1 Other ❑ Delta Depth of Grout Sea Type of Grout <br /> M frngation `; pprox. Depth ❑,Eastern Surface Saai Installed by <br /> Repair Work Dona. Type of Pump I H,P. State Wor ne_ <br /> Well Destru ju Waal Diameter f Sealing Material 4 Depth. <br /> Depth ^ —riller Nit-trial i Depth <br /> T-PE Of SEPTIC WORK: NEW INSTALLATIOA REPAIRIADOITION M DESTRUCTION 7i iNo•septic system permitted if public sewer is <br /> 1 —4 � ) available within 200 feat.! <br /> Installation will serve: Residence_s Commercial ther <br /> Number of living units: Number of bedrooms C <br /> Character of sod to a depth of 3 feet: X �✓ G r �`�� Water table depth <br /> i SEPTIC TANK. T C1'G <br /> vpe/Mfg �'�� � � Capacity Na. Compartments <br /> PKG. TREATMENT.PLT.0 f ' I /-1y�1, Method off.DD dal (f <br /> Distance to nearest: (Well ��./t Foundation Property Property Line <br /> LEACHING LINE ❑ No. & Length of lines a' Tvtal length/size <br /> FILTER BED ❑ Distance to nearest: Foundation I0 _ Property Line ;r7jn" <br /> i SEEPAGE PITS 11 Depth Z Sias'ZS Number (- <br /> SUMPS Ll Distance to nearest: Foundation �_ Property Line <br /> NOiSPOSAL PONDS Cl `, (' <br /> I hereby certity that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, attd_ <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, I shall not <br /> employ any person in such manner as to become subject to workman's compensation Jaws of California."Contractors hiring or sub-contfacting signature <br /> certifies the following:"I canify that in the performance of rhe work for which this permit is issued,t shall employ persons subject to workman's compensa- <br /> tion laws of California." I <br /> The applicant mustI for all re ed inspections. Complete drawlngon ✓'.� . <br /> _revs <br /> sida.._ <br /> � X Signed X Title: Date: <br /> FOR -USE ONLY <br /> l . Application Accepted by ng �ha��L. Data ~�j' Ares <br /> Pit or Grout Inspection by DateFinal InspectionDate / l <br /> Additional 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 O BOX 2009, STOCKTON, CA 95201 <br /> IFEEO OUNT DUE AMOUNT REMITTED CASH CK I RECEiVEO BY DATE PERMIT*NO. <br /> EH 13.241REY.i/ 6� <br /> EH'.4.26 <<J CJ <br />