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APPLICATION FOR PERMIT <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 /> PERId T ESPIRES I YEAR FROM DATE ISS19M <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 Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San -Jr* <br /> Joaquin County Public Health Servi es. <br /> l -2 / Y 0 V R D 0.10 City C` L4Talot Size/Acreage acK <br /> Job Address � <br /> 0 J Phone <br /> Address <br /> Owner's Name <br /> E <br /> contractor Address License No. Phone <br /> Out of Service Well ❑ <br /> TYPE OF WELL/PUMP: NEW WELL L4WELL REPLACEMENT C7 DESTRUCTION Ll <br /> Monitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 11OTHER ❑ ❑ <br />{ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ISPO L FLD. PROP. LINE <br /> FOUNDATI 1C URE OTHER WELL PITS/SUMPS <br /> INTENDED USE TYP OF W L PROBLEM CONS CTIONV SPECIFICATIONS <br /> ' I-] Industrial ❑ pen Bottom nteca Dia. of Welt Excavation` Dia. of Well Casing T <br /> f l Domestic/Private Gravel Pac ❑ Tracy Type of Casing. Specifications <br /> 3-.1 Public Cl Other # 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 ?.�— H.P. State Work Done <br /> f Well Destruction 0- Well Diameter Sealing Haterial 3-i Depth <br /> Dept„ biller Materis.14 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIRIADDITION IPI DESTRUCTIO ptic system permitted if public sewer is <br /> I available within 200 feet.) <br /> Installation will serve: Rest nce Commercial T Other r (� <br /> Number of living units: Number of b*4rporn <br /> Character of soil to a depth of 3 fast: Water table depth � �V <br /> -SEPTIC TANK ❑ Type/Mfg �- ✓ Capacity Q No. Compartments . <br /> i r Method of DispoFal 1 <br /> f PKG. TREATMENT PLT. ❑ '41 ! (5 1 <br /> r Distance to nearest: Well Foundation S Property-Line?00 <br /> 1i <br /> LEACHING LINE No. B Length of lines r Total length/size _ <br /> FILTER BED O' Distance 16 rtearest� Well 20 + — Foundation_ _ Property Line .,*?no <br /> .. <br /> s SEEPAGE PITS Depth Size 3(� ok i G-- ---- Number <br /> SUMPS a Distance to est: Well <br /> ell'1 FoundaYon roperty Lie n <br /> 4�1 11 <br /> DISPOSAL PONDS ❑ -,-^ �� • b �- /_ <br /> f 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 s. <br /> Home owner or licensed agent's signature osrtifies 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 workmen's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies ttm fonowing:"I certify that in the performance of the work for which this permit is'issued, I shall employ persons subject to workman's compansa• <br /> tion laws of California." ' I <br /> k The applicant mus cap all it inspgctio . Complete drawing on,7rse side.X. �7 g7 <br /> Title: - Data: <br /> f 2-1C " <br /> Signed <br /> FOR DEPARTMENT USE ONLY <br /> Applic ti Ace y Date .n! /r/ Area ---- <br /> Pit of Grout Inspection by/ Dal ef t _ Final Inspection by , _ Data <br /> Additional Comments: <br /> 1 <br /> -Applicant - Return all copies to: San Joaquin County Public Health Services <br /> r <br /> Environmental-Health Permit/Services <br /> 0 445.N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> IFEE <br /> NFO AMOUNT DUE -i AMOUNT REMITTED I C SH RECEIVED BY DATE PERMIT'NO, <br /> l EH13-24inrEv.lifts) / / � <br /> EM n � !'i •r�� <br />