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APPLICATION FOR PERMIT �5:. S <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 6�- PI'S' <br /> . (209) 468-3447 J <br /> P 1 YEAR ATE—MUM <br /> (COtttpidte in Triplicate) <br /> Application is hereby made,to San Joaquin County for a jnrmit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin Coun'Ly Ordinance No. 549 and 1862 and the Rules Lad Regulations of San <br /> Joaquin County Public Health Services. � <br /> � _ s �, �yt1 �RT:L� City � :5 No. <br /> .— Gat Size/Acreage „J7p — <br /> X�Z-� <br /> 17 ,f <br /> Job Address <br /> pEDWAP-D S- A/Gedlg 4;,— Address 3`E 1 g O' D - Phone � 333� <br /> i4 Owner's Name - <br /> t �(� ifjhs<L C/✓�T License No, �Sy�G _Phone X-397/ <br /> Contractor GO Address - <br /> TYPE OF WEL'l-/PUMP: NEW WELL ❑ VNELL REPLACEMENT ] DESTRUCTION Ll Out Of Service Well 0 <br /> Monitoring Well <br /> t rPUMP INSTALLATION 1) SYSTEM"'RE L] —OTHER O <br /> DISTANCE TO NEAREST: SEPTIC TANK WER LINES DISPOSAL FLD, PROP. LINE <br /> f FOUNDATION AG CUL,TU ELL OTHER WELL PITS/SUMPS <br /> i <br /> INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS <br /> I .- Dia. of Well Casing <br /> I fl Industrial ❑ Open Bottom Q Man - a i Dia. of Well Excavation <br /> * - — - <br /> specifications <br /> U Domestic/Private Cl Gravel Pack acy i e of Casing <br /> ID Public ,,� I'1 Other !� Delta � Depth Grout Seal <br /> Type of Grout <br /> CJ Irrigation �..Approx. pth 0 Eastern Surface Seat Installed by <br /> Repair Work pons, L] Type of Pu p State Work Done <br /> H.P. <br /> s SeLI].ng Material i Depth F <br /> Wetf Destruction ❑ Well Diameter <br /> Filler Material i Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIAC.IDITION 0 DESTRUCTION (No septic system permitted if public sewer is v i <br /> available within 200 feet.i <br /> Installation will serve: Residence Commercial____ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of$ feet: Water table depth r <br /> SEPTIC TANK ❑ Type/Mfg —"'" Capacity ^�No Compartments <br /> t PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> f <br /> LEACHING LINE Cl No. & Lingt6E6f lines Total length/size <br /> FILTER BED n Distance to nearest: Well t Foundation Property-Line <br /> SEEPAGE PITS 11 Depth:, Size Number <br /> l SUMPS Ll Distance'to nearest: Well C Foundation Property Line <br /> DISPOSAL PONDS Ll <br /> I hereby certify that I have prepared this application and that the vlork will be done in accordance.-with San Joaquin county-ordinances, state laws, end <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: " 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 workm In's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the workifor which this permit is issued, I shall employ persons subject to workman's compensa <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete dravl�ing on reverse side. <br /> Signed X �--�� Tikls: Date: `9 <br /> FOR DiPARTMENT USE ONLY i <br /> Application Accepted by Date r Area <br /> Pit or Grout Inspection by Date Final Inspection by Date %l <br /> Additional Comments: <br /> Applicant Rat= 911 copies to: -"dAN JOAQUIN COUNTS, PUBLIC HEALTH SERVICESr <br /> " ` ENVIRONMENTAL-HEA1:,TH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN,'i P 0 BOX 2009, STOCKTON,•,CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMiTTEO� CA5� iiECEIVEO 8V DATE PERMIT N0. <br /> INFO <br /> . EH 13•24[REV.IIN$) �W .O� !� �� � 1C �•� "� � i���o <br /> EM,�•� 111 � - <br />