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f <br /> APPLICATION FOR PERMIT <br /> ' <br /> SAN JOAQUIN COUNTY PUBLICDIVISION VICES <br /> ENVIRONMENTAL HEALTH <br /> p O BOX 2009', STOCKTON, CA 95201 <br /> (209) 468=3447 <br /> PRRMIT <br /> � (Complete in Triplicate) <br /> Application is hereby made to Sean JoahunCunto�o�permit <br /> ty OrdinancenNoruSkgand/or <br /> 1662 and thethe <br /> Aules audherein <br /> Ragulationadescribed. <br /> of Sano <br /> l application is made in coa�+liance_y1 Joaquin <br /> Joaquin County Public Health Services. <br />+ > /�• City Lot Size/Acreage <br /> =Job Address <br /> �— <br /> f Address Phone <br /> -Owner a Name <br /> �.d.. � 1r�` Ad s 7& ' 'v iiW 7/C �License=No. f' /V7�hana <br /> Contractor , <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ D TRUCTION ❑ Out Monitoring Well <br /> Service Well ❑ <br /> PUMP INSTALLATION ❑ f SYSTEM REPAIR ❑ <br /> OTHER ❑ MoC7 <br />�k DISTANCE TO NEAR SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> I FO ON AGRICULTURE W OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL BLEM ARE ONSTRUCTION SPECIFICATIONS <br /> f_� Industrial ❑ Open Bottom 0 Man Dia. of Well Excavation <br /> Dia. of.Well Casings <br /> roc of-Casing Specifications- <br /> U Domestic/Private ❑ Gravel Pack y Type of Grout <br /> M Public ["I Other ❑ Delta, ---Depth of Seal <br /> CI IrriUa#on _ raw"Depth 0 Eastern Surface Seal instal <br /> Repair Work Done 0 ype of Pump c H.P, State rk Oone-_ <br /> Sealing Material & Depth * - rp <br /> Well Destruction O Well Diameter <br /> Depth f ► Filler Material & Depth IV "5 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION CI REPAIR/ADDITION M DESTRUCTION <br /> (No septic system permitted if public seweris <br /> available within 200 feet.) T �n <br /> Z. V' <br /> Installation will serve: Residence Commercial"� Other <br /> ) Number of living units: Number of bedrooms �. _ . <br /> depth <br /> s <br /> Cha►acter at soilto a depth of 3 feats � r Water table. <br /> SEPTIC TANK �C� Type/Mfg Capacity 4No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal - <br /> Distance to nearest: Well Foundation Property Line -. <br /> " t � <br /> LEACHING LINE ❑ No. & Length of lines _ ) Total length/E s� i <br /> ze <br /> FILTEA.BED ❑ Distance to nearest: Wel Foundation Properly Line <br /> SEEPAGE PITS 11 Depth Sizet Number <br /> SUMPS, Ll Distance to nearest: Well` Foundation Property Line <br /> "DISPOSAL PONDS ❑ <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 /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following. "I cartify 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 laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following: "I certify that in,the performance of.;he work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Calif " - <br /> The appiican Ire coons. C plate drawing on reverse SOO/ <br /> Is Dat <br /> t r I" Date: <br /> Signed Ti '� _ w <br /> `- <br /> F DEPAriTMENY USE ONLY <br /> Application Accepted by - Aru��.��• - Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> 4;Z <br /> t— a f <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 /> CK I <br /> EEE AMOUNT DUE; fOL)NT REMITTED CASH <br /> RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> . EH 13-74 1REV.I/n 51 .Q 0.-f��.J 1J •'� �' L , R F �"f��� <br /> EH 34.2e. ` 1 64 <br />