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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION 3 00 � 1 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468--3447 <br /> YEAR <br /> (Complete in Triplicate) <br /> Application is hereby rands to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in compliance vith San Joaquin County Ordinance no. 549 and 1662 and the Rules acid Regulations of San <br /> Joaquin County Public Health Services. <br /> ,Louls,r:� Arm WT�T`O7� Biu/uy 1�r9clHC Q. <br /> Jab Address OaOC& /9,5 —2�P=1G _ _ _ City L�FT/tfiPlT/� _ Lot Size/Acreage CJ./_2Q <br /> Owner's Name 2/a!}Address /F773-S. 7TH, !7,, . 1, _ Phone <br /> Contractor f`)J?LLJ( Address 360 S - C4ense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL-,C ! WELL REPLACEMENT 0 DESTRUCTION 0 Out of Service Well Ll <br /> PUMP INSTALLATION ❑ WAF SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well, C� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC TIONS <br /> 0 Industrial 0 Open Bottom �anteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications <br /> 'Public �Other ❑ Delta Depth of Grout Seal Type of Grout <br /> 0 Irrioation " _.Approx. Depth d Eastern Surface Saul Installed by <br /> Repair Work Done L3 Type of Pump H.P, State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth n/�((�� A <br /> Depth Filler Material A Depth WK'rw\ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION M DESTRUCTION 0 (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> w Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Silo 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 certify that in the performance of the work for which this permit is issued, 1 shall not i <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring of sub-contracting signature <br /> certifies the following: "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 <br /> The sppiic st f r all pections. Complete drawing on r r" side. <br /> Signed Title Date: (' <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by bhhM,vp_,4�� Date %A A <br /> PI; or Grout Inspection by Date Final Inspection by Data/=� <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES A <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O SOX 2008, STOCKTON, CA 85201 <br /> FEE MOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO, <br /> INFO CASH <br /> . EH 13.26IREV.iinSi /�/'1 �� Q <br /> EM:x•26 � / 5EJ <br /> tf f G <br />