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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> EN V I RONNdENTAL HEALTH DIVISION .bot"' Cit <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROMAT $ JVD' <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 coargrliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County blit Health Services. <br /> Nr /,dLO /V. ��� City 6,6L/)PAI [ <br /> TocKT�l�' Lot Size/Acreage <br /> ���'e'RF <br /> v Job Address . C7 ;Z4/V I <br /> Owner's Name WHOP r Address 6AtA Phone — r S <br /> Conlraclor s/ L/ Address License No. Phone <br /> TYPE Of WELLIPUM <br /> P: NEW WELL ❑ WELL REPLACEMENT 17 DESTRUCTION cl Out of service well ❑ <br /> r Monit ng well �� <br /> P INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER <br /> DISTANCE TO NEAREST: SEPTIC SEWER LINES DISPOSAL FLD PROP. LINE <br /> FOUNDATION" (CULTURE WELL ELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM A RUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom anteca Dia. of Well tion Dia. of Well Casing <br /> C1 Domestic/Private ack =1❑.Tracy ,,.Type of Casing Specifications, <br /> V1 Public 1-1-Other sf. Cl Delta Depth of Grout Seal Type of Grout <br /> t l Ifriga ion AcN <br /> ppiox. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ .Type of Pump 'yr H.P. State Work Done <br /> Welt Destruction ❑ Well Diameter Sealing Material & Depth <br /> - pepih Filler Material & Depth <br /> I <br /> i TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR IADDITION I I DESTRUCTIONINo septic system permitted if public sewer is <br /> available within 200 feet.) <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. ❑ 'i Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of,Disposal <br /> Distance to nearest: Well Foundation Property Line` <br /> LEACHING LINE ❑ No. & Length of lines. Total length/size <br /> FILTER BED Cl Distance to nearest. Well Foundation Property Line <br /> a SEEPAGE PITS l I'i Depth { Size Number <br /> SUMPS LI• 'Distance to nearest: Well Foundation Property Line <br /> I DISPOSAL PONDS a l❑ <br /> I 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 /> i 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 pirson in such mianner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's <br /> compensa-tion laws of California." " <br /> { The applicant must call for all required tnspe.cti ns. Complete drawing on reverse side. <br /> t <br /> Signed X <br /> GtJt o - Title: Date: <br /> i FOR DEPARTMENT USE ONLY <br /> f Application Accepted by Date Area <br /> k Pit or Grout Inspection by Date Final Inspection by _ �' Date <br /> i a <br /> Additional Comments: <br /> r <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 d <br /> FEE AMOUNT DUE AMOUNT REMITTED CK I RECEIVED BY DATE PERMIT NO. �� 1 <br /> 1 INf{FFO' l�Jjj � CASH �(�'�j^y 114, <br /> r/s t^{ /4�/!I 1 aEH13-2{IREV.rfn51 � ''y:q•� �{l• y ' ' f+�. l� {`R,.�':l-( <br />