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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> 1 P 0 BOX 2009, STOCKTON, CA 95201 <br /> iPERYIT EXPIRES 1 YEAR FRQM_DATE ISSUED <br /> 1 (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. l <br /> .fob Address - City Lot Size/Acreage f <br /> Owner's Name �U�� _ Address / !d � " n"4� Phone � r <br /> Contractor � ` � # Address License Phone <br /> TYPE OF WELL/P MP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION 0 Out of Service Well 0 <br /> UMP INSTALLATION ❑ SYSTEM ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEP TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATI t AGRIC RE WELL OTHER WELL PITS/SUMPS i <br /> INTENDED USE TYPE OF WELLAREA CONSTRUCTION SPECIFICATIONS <br /> C1 Industrial ❑ Open Bottom Mantec Dia. of Well Excavation Dia. of Well Casing G <br /> D Domestic/Private 0 Gravel P ❑ Tracyof Casing Specifications i <br /> F1 Public f_1 0 r V1 Delta Depth o 1 Seal Type of Grout ' <br /> I Irrigation f Approx. Depth fl Eastern Surface Seal lnsta r <br /> Repair Work Done U Type of Pump H.P. State k Dona <br /> Well Destruction ❑ Well Diameter sling Material & Depthr- <br /> Depth 1 Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTAL REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted if public sewer isl ! <br /> available within 200 feet.l <br /> Installation will serve: Residence Commercial_ Other t <br /> Number of living units: -L— Numberrof bed oms � ; <br /> Character of soil to a depth o(3 feet: t Water table depth <br /> SEPTIC TANK. Type/Mfg apacity,4;2annO— No. Compartments <br /> PKG, TREATMENT PLT. ❑ �} Method of Disposal <br /> Distance to nearest: Well Foundation =2 f) Property Line <br /> o i <br /> LEACHING LINE No. & Length of lines _ 410 Total length/size <br /> FILTER BED ❑ Distance to nearest; Well �� Foundation Property Line—f-=-_---__ <br /> SEEPAGE PITS *--Depth Size Number <br /> SUMPS LI Distance to nearest: WellIon Foundation� Property Line / <br /> DISPOSAL PONDS ❑ I �; <br /> 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, an <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 workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the follofo 'I 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 Cali <br /> ." <br /> i <br /> The applicant mCarl for all fired ' chess.-Gomplete drawing on reverse side. J <br /> Signed Title: - _ _._ Date: / <br /> -ENT USE ONLY <br /> Application Accepted by Date _ Areas <br /> it or Grout Inspection by Date final Inspection by D�te,��� <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Bax 2009, Stockton, CA 95201 <br /> FEE i <br /> INFO AMOUNT DUE AMOUNT REMITTED . GASH RECEIVED BY DATE PERMIfT'[N�O(�I'' <br /> a EM 14-21IREV.s/es! l f �� 17,111-(bL.. `/�% L U ���( �! <br /> EFS 71.2a <br />