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f APPLICATION FOR PERMIT 4 <br /> s <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 ' <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM D,&T9 I S <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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> 1� f7 Lot Size/Acreage <br /> Job Address � ..-_� GL-1u� — City ` <br /> a r <br /> Owner's Name Address z1aLa- _ Phone <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUM NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C] <br /> DISTANCE TO NEAREST: SEPTIC TANK t SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION' AGRICULTURE WEL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM A fiONSTRUCTION SPECIFICATIONS <br /> 0 Industrial O Open 8 r s-- -- :ot—We�l Excavation_ __ _ Dia. of Well Casing # <br /> F) Domestic/Private ravel Pac ❑ Tracy Type of Casing_ _ Specifications I <br /> l'I Public 1--1 Q n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation ..._._Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump I H.P. State Work Done <br /> Well Destruction O 'Well Diameter 't` Sealing Material i Depth r <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION I I DESTRUCTIO lf+lo septic system permitted if public sewar is <br /> aillable within 200 feet.) li <br /> Installation will serve: Residence—-Commercisl Other <br /> Number of living units Number of bedrooms Q <br /> Character of soli to a depth of 3 feat: Water table depth <br /> SEPTIC TANK. © Type/Mfg = t No. Compartments <br /> PKG. TREATMENT PLT.❑ , ,�i�ietl r "11 Method of Disposal -t <br /> Distance to neereat:PerMtf�a"�° �� Property Line �} <br /> comp d or insp <br /> LEACHING LINE 0 No. 6 length of IiWprk being 11,,,,��h n',f'�.1ore length/size <br /> FILTER BED G) Distance to nearesuby � LAW82i�ki Division Property Line ` <br /> SEEPAGE PITS 11 Depth I Sire Number <br /> SUMPS L1 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 Sen Joaquin County <br /> Home owner or licensed agent's rignatu►e certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any parson in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature ! <br /> certifies the following: "1 certify that in the performance of the work for 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 r Ir spoetions. Complete drawing on reverse side. /` Q <br /> Signed Tine: Date: <br /> - I <br /> FOR DEPARTMENT USE ONLY S'� C;?' /)-- <br /> Application Accepted by <br /> Date / J Z Area <br /> Pit or Grout Inspection by Date Final Ins ction bff ppDatelI � <br /> Additional Comments: �.! �l l CC (LCZ4 y� <br /> Applicant - Return all copies to: San Joaquin County Public Health Services r� <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'N0. <br /> INFO r� CASH <br /> . EK M24 IREV.r/R 51 �`y. >;- ; tJ� �� L (i 'f '� 2—c21 <br /> EH t1•3a <br />