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1 <br /> APPLICATION FOR PERMIT <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 /> PERifIT E%PIRES Y FRO M[ DATE LSOMj <br /> (Complete in Triplicate) <br /> Joaquin County for a permit to construct and/or install the work herein described. This <br /> Application is hereby laude to San <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� - 4 AG2 s j <br /> r S 1[ <br /> City Lot Size/Acreage • <br /> Job Address L I f n_ K <br /> -��_� •/�YV ! ©�Q W_.���/ � DLU.� Phone <br /> {�� Address � <br /> Owner's Name Z I s�r��,e r L as S / jG/� <br /> Address o /Z 5idck-16A) License No.49W <br /> phone <br /> ontractor LGP DESTRUCTION ❑ out of Service Well ❑ <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 14onitoring Well ❑ <br /> PUMP INSTAL I � <br /> T REPAIR ❑ OTHER ❑ <br /> R LIN <br /> I[yt•4rSAl FLD. PROP. LINE <br /> DISTANCE TO NEAREST: <br /> SEPTIC TANK C,}� C LTU EL` 0 WELL PITS/SUMPS <br /> FOUNDATION , <br /> Tl�Ij�f; IFICATIONS ,. r <br /> INTENDED USE _TYPE OF WELL �� Q �srrr+�tx� D"f"Weil Casing <br /> 0 Industrial ❑ Open bottom �(ftgca` ! xcavati n <br /> W�� , ����� ���}� ����I�� �� -,Specifications r <br /> Cl Domestic/Private ❑ Gravel Pack f. a • r' Type of Grout <br /> I'1 Public 1.1 Ottttir � by lP11MLi .i� r �1�EflU Y " <br /> I I Irrigation -.Approx. Depth l I Eastern Surface Seal Installed by. <br /> H P - ' State Work Done <br /> Repair Work Done U Type of Pump <br /> ! Sealing material a Depth <br /> Well Destruction ❑ Well Diameter �-- tiller Materii:l i Depth <br /> Depth <br /> I TYPE Of SEPTIC WORK: NEW INSTALLATION I I REPA�_ADDITION l I DESTR TION aNailablelw thin 200 system feei�led i! public sewer is <br /> k Installation will serve: Residence Commercial Other <br /> Number of living unite Number pf bedrooms .. Water table depth <br /> Character of son to a depth of 3.feet No. Compartments <br /> -'' <br /> SEPTIC TANK. ❑ CapacityTyps/Mfg: <br /> �,.•' -A � Method of Disposal �t <br /> PKG. TREATMENT PLT. ❑ s` � Property Line <br /> Distan- to nearest: Well Foundation <br /> j <br /> Total length/size <br /> LEACHING LINE- y ❑ No. b Length of linea <br /> fProperty Line- <br /> FILTER BED Cl Distance to nearest: Wei! Foundation <br /> 1 <br /> SEEPAGE PITS 11 Depth I Sue Number <br /> SUMPS LI Distance to nearest: Well �.Foundation 'Property Line <br /> DISPOSAL PONDS ❑ <br /> ftC7 <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 /> mploy any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> e <br /> certifies the folowing:111 certify that in tape performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> he applicant must call for all required i spa. ions. Co plata drawing on reverse sides �� Z <br /> Title: S ' E �L Date: <br /> I Sp^� <br /> F R DEPARTMENT USE ONLY G+ <br /> Date l L Area f <br /> Application Accepted by <br /> " Date..�-- Final Inspection by Date <br /> Pit or Grout Inspection by <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County public Health Services <br /> ] Environmental Health permit/Services <br /> ia.. 445 N San Joaquin, P 0 Box 2009, Stkn, GA 95201 <br /> r # CK <br /> FEE AMOUNT DUE AMOUNT REMITTED '__CASH RECEIVED BY DATE PERMIT NO. <br /> INFO 7� G� <br /> . EH 13.24 INEV.B its) ![�V C O� 310 dT( I L Z l 1 <br /> EH 14.20 <br />