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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HRALTH S$RVICES ` <br /> / MV I RONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 —= <br /> I <br /> ERS T FXPIRES 1 YM FR9_M DATE laSPEDI <br /> (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. r <br /> A <br /> Job Address L2 10!l City J Lot Size/Acreager�gx <br /> / } rs <br /> Owner's Name l .4¢a.� Address ' Phone <br /> ^ <br /> contractor.; - Address _ .License_l!l_ .�,J� J /1�Phone 172 <br /> TYPE OF WELL/PUMP: IF NEW WELL ❑ ELL REPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ <br /> TA <br /> PUMP.INS [LATIOiCSYSTEM PAIR El OTHER ❑ a Monitoring Well L] <br /> DISTANCE TO NEAREST:-SEPTIC TANK SEWER LES DISPOSAL FLD. PROP. LINE <br /> f <br /> ii <br /> FOUNDATION f; AGRICUL UR ELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM ARE CONSTRUCTION SPECIFICATIONS .f <br /> ❑ Industrial ❑ Open Bottom ❑ Mantec Dia.-of Well Excavation Dia. of Wall Casing <br /> ___. . <br /> [a DomesticlPrivate "GI-Gravei Pack""" ❑'Tia Type of Casing Specifications <br /> i'I Public t fel Other n Its Depth of Grout Seal Type of Grout - <br /> I € Irrigation _Approx. Deptif I astern Surface Seal Installed by <br /> Repair Work Done IJ Type of-'Pump'- '` j H,P. •' State Work Done_ <br /> Well Destruction D Well Diameters 3 Sealing Material i Depth <br /> Depth j I Tiller Material A Depth. - ' <br /> TYPE OF SEPTIC WORK:>-,NEW INSTALLATION ['I REPAIR/ADDITION f I DESTRUCTION I I (No septic,system.permitted if public sewer <br /> ,/ `0 vailabl "'within 200 feet.1 <br /> Installation will serve: Residence Commercial ' Oihor / <br /> Number of living units:-=--- Number-of-bedrooms r(�� �f�� <br /> Character of soli to a depth of 3 feet: t at or td6Af depth <br /> SEPTIC TANK. T /Mf `"1 - 'e <br /> ype g Capacity No. Compartments <br /> PKG. TREATMENT PST:Ll t r w `� Method of 015009111 <br /> p.�W Distanr:e`to_nearest' Welll Foundation Property Line <br /> LEACHING LINE No. & Len tW f linesLV i <br /> - 9 Y T_ 1 length/size <br /> pyx ', - <br /> FILTER BED ❑ Distinca to nearest Weil fJ Foundation Property Line <br /> SEEPAGE PITSDepth iSiieber } . <br /> SUMPS LI Distance sof rest: well - FoundationProperty Line <br /> DISPOSAL+PONDS ❑" ZP <br /> --µmw 1 / <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 mgulations-of the San Joaquin County r <br /> Home owner or licensed agent's signature certifies the following:-�"l certify that in the performance of the work for which this permit is issued, I shell not <br /> employ any person in such`manrir as to become subject to workman's compensation-laws of California."Contractor's hiring or sub-contracting signature <br /> cenifies the'fo#O%Ving: "I certify-thitin the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Colifornfi.';,. <br /> The applicant mit loll-for alt r insp t' ns. Complete drawing on reverse side. <br /> Signed ` Title date: ` <br /> 4- <br /> FO DEPARTMENT USE ONLY <br /> Applicatlon,Accopted by 60Date Area a 2_1 1 <br /> Pit Grout I <br /> nspection by Date Final Inspection by; Date <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 O Box 2009, Stkn, CA 95201 <br /> I } <br /> ? lFEEO AMOUNT DUE { AMOUNT REMITTED CA RECEIVED BY DATE PERMIT-NO. <br /> + ENt4.2111EV.iie4Y50 <br /> EH a-x (f ! AN �// <br />