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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> O< ENVIRONMENTAL HEALTH DIVISION <br /> ! 445 N SAN JOAQUIN, PHONE (209)468-3424 <br /> !1a ,� P O BOX 2009, STOCKTON, CA 95201 <br /> I <br /> 16?3 - l80- e�x <br /> _PERMIT EXPI RES 1 YEAR FROM DATE ISSUED <br /> l � t,34 (Complete in Triplicate) <br /> Application is hereby made,to Sac 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 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. /� <br /> Job Address . � , L-ef.. — City Int Size/Acreage <br /> 7s Owner's Name Address Phone tJ <br /> l � ^ <br /> a Contractor Address [ License No. hone <br /> t TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION Out of Service Well Gl <br /> Monitoring Well <br /> PUMP INSTALLATION ❑:( SYSTEM REPAIR C] OTHER ❑ C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK aa--- SEWER LINES DISPOSAL FLD.Al'&_ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC TI*S y <br /> �Cl fIndustrial ❑ pen Bottom ❑ anteca Dia. of Well Excavate, n Dia. of Well Casin <br /> Domestic/Private 'Gravel Pack racy Type of Casing. Specifications <br /> l'1 Public 1--1-�O}ther ✓✓✓O___Delta Depth of Grout Seal f Type of Grout2&k <br /> I I Irrigation -V—Approx. Depth I I Eastern Surface Seal Installed by_am 3ef- - <br /> Repair Work Done U Type of Pump �— H,P. State Work Done_ <br /> Well Destruction ❑ Well Diameter 16 Sealing Naterial i Depth 4 .f l <br /> f Depth filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will terve: 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. 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ r Method of Disposal <br /> I Distance to nearest: Well Foundation Property Line <br /> I! <br /> LEACHING LINE Cl No. & Length of linea Total length/size <br /> FILTER BED Cl Distance, to nearest: Well Foundation Property Line <br /> I <br /> SEEPAGE PITS 11 Depth t Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Lina <br /> i DISPOSAL PONDS- ❑ t <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 sub-contracting signature <br /> candies 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 Calffor <br /> The applican foreadnspections. Complete drawing on r8%*side. — <br /> Signed d Title: n p�_ Date:loor w <br /> FOR D ENT USE ONLY <br /> Application Accepted by Date ,.._,C��„�`a— 1� Area <br /> Pit or Grout Inspection by Date Final Inspection by Lr. AA A. Data <br /> t1$eaA Out- )ah '7'6�`c A [� o�oZa <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 D Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMtTTEO CK RECEIVED BY DATE PERMIT'NO. <br /> INFO a I OCA <br /> . EH 13-24(REV.I/K51 D Q / r� ! <br /> fH 14.20 u <br />