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APPLICATION <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 DATE ISSUED <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 coMliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address :3 x/�-L-_- City ^rt ----- Lot Size/Acreage <br /> Owner's Name r Address Phone <br /> Contractor L Addresa3::M IA-21 License No, Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLAC�NT Cl DESTRUCTION o Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR _q OTHER C3 Monitoring well L3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE <br /> FOUNDATION AGRICU ELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBL fr CONSTflUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ti q yr ";5 Dia. of Well Exca on Dia. of Well Casing <br /> [I Domestic/Private ❑ Gravel Pa � g%cy Type of Casing_ Specifications <br /> l'I Public f.1 �Z,� 12apth of Grout Seal Type of Grout <br /> Y <br /> I I IniUatiot+ 4�� �. Depfh �I tern,. ~Surface Seat Installed by <br /> Re orkg4 � of P � H.P. __ State Work Done_ <br /> Well astruction CI or Sealing Material i Depth <br /> pth" Filler Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITIONI�Df:STRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installsfllprywill serve: Rea*denca._1--c-ommercial Other <br /> Number�ot living units: Number of bedrooms Itsft� <br /> Character of soil to a depth of 3 feet: C2 La Water table depth \v <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal (� <br /> Distance to nearest: Well Foundation Property Line 11V <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Lina <br /> f <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS kj,BiSfancq tonear . Well Foundation Property Lina . �7 <br /> DISPOSAL PONDS ❑ I <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 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 /> cert't' ha following: "I ce ify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion wa alifornis." <br /> The applitan t call f ad it s ct ons, omple drawing on reverse si e. <br /> Sign e: [-�� Date: w <br /> EPARTMENT USE ONLY <br /> Application Accepted by �1K�tn�. ` O .wn/�� ,_ Date Area 0 I'S S&i <br /> Pit or Grout Inspection by Date Final Inspection by ���, Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CA RECEIVED BY p TE PERMIT NO. <br /> . EH 3-24IpEV.fKk <br />