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• h 1 <br /> 4 � <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC REALTU SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009t , STOCKTON, CA 915201 <br /> (209) 468-3447 <br /> 2EMIT_MX S_x XBAA E.BQXL DATE_IiQS111M <br /> ,Complete n/?or,.t <br /> plica e) <br /> Application is hereby Leede to San Joaquia Coin fora o c and o ns Y1 t e he a described. This l <br /> application is made in CORPliance with San <br /> r'J uin rya t 0rdina ,e H,4 4 and 1862 and the Rules and Regulations of San <br /> J i }�ltly� ✓""i'til f�/ � Jll/t//�� �� <br /> `>Ir I, � ff�� <br /> Job Addreaa _ - - City Lot Size/Acreage [2r`,r9L ( <br /> Owner'• Name , �[yQ Address rte <br /> Contractor`&Ohl=Dam A// Address S gnse No. Phone <br /> TYPE OF WELL/PUMP: NEW WELf� Ou <br /> WELL REPLACEMENT n DESTRUCTION ❑ t of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 a <br /> DISTANCE TO NEAREST: SEPTIC TANK '-r SEWER LINES DISPOSAL FLD. � PROP. LINE <br /> FOUNDATION) �. -„ _ _AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom,._ EF1'Mantecs Dia. of Well ExcavationfJJ4Aff44 Dia. of Well Casing C -4 <br /> U Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public 1:I Othgr Q t ❑ Delta Depth of Grout Seal �1�r� Type of Grout p <br /> cpdifrioalion �Ap�alr. Depth 0 Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pumpl H.P. State Work Done_ r <br /> Well Destruction ❑ Well Diameter,.1 Sealing Material i Depth <br /> Depth f Filler Material 4 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION LI REPAIR/ADDITION M DESTRUCTION ❑ INo septic system permitted if public sewer is <br /> available within 20D feet.) <br /> Installation will serve: Residence_F4Con+mercial Other <br /> Number,of living units: Number of bedrooms <br /> Character of soil to a depth pf 3 feet. Water table depth <br /> SEPTIC TANK. ❑ type/Mfg ' Capacity No. Compartments ! t <br /> PKG. TREATMENT PLT,Cl. Method of Disposal <br /> Distance to nearest: Well Foundation Property Lina <br /> LEACHING LINE 0 No. A engtrLlines Total length/size <br /> FILTER BED f7 Distant tonnsit Foundation Praperty LineSEEPAGE PITS I I Depth ' ze Number <br /> SUMPS LI Distance to`nell 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, 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 subcontracting signature i <br /> cenilies the following;"t certify th t 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 liforn a." r <br /> The app' nt c for I Inspections. Complete drawing on r v I�Wd f <br /> (Signed Title: bete: C <br /> j F DEPARTMENT USE ONLY Q j <br /> Application Accepted by Dote ��a "� l 0 Area i <br /> �o- ,I <br /> Pit or rout napection byitz Date/ incl Inspection by< l paw <br /> .Additlonal Comments: -� �d �` a A <br /> Applicant — Return all c es to: AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES i <br /> s ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O SOX 2009, STOCKTON, CA 95201 i <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO, <br /> INFO CASH <br /> EH 141.20 I11EV.I,its) °l 0 C.' \C�- . — 1 !b 1a a <br />