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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES -7/51 t <br /> ENVIRONMENTAL HEALTH DIVISION J <br /> -P 0 BOX 2009, STOCKTON, CA 95201 <br /> I (209) 468-3447 <br /> - tPERMIfi MIRES IYrAR OROM DATE ISSUgU <br /> (Complete in Triplicate) <br /> Application is hereby Slade 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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> ' <br /> � Job Address <br /> ` q �� S � QI �d City Lot Size/Acreage <br /> Owner's Name O L_�l l J I OC9 ems/ Address ` Phone _ l <br /> '1 r <br /> �Cantracfa _� � ' Address Sri`^-C� License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION G Out of Service well ❑ l <br /> t <br /> PUMP INST ATION 03 _ SYSTEM REPAIR ❑ OTHEfl ❑ Storing well <br /> DISTANCE TO NEAREST: SEPTIC TANK f SEWER LINES DISPOSAL FLD PROP. LINE I <br /> FOUNDATION l !CULTURE WELL ELL PITSJSUMPS T <br /> INTENDED USE TYPE OF WELL PROBLEM AREA TION SPECIFICATIONS <br /> 1_1 Industrial 0 Open Bottom ❑ Ma Dia. o I Excavation Dia. of Weil Casing <br /> U Domestic/Privete C} Gravel Pack Tracy Type of Casing Specifications <br /> M Public !-1 Cl Della Depth of Grout Seal Type of Grout <br /> M Irrigation _.Approx. Depth ❑ Eastern Surface Seul-Installed by (� <br /> Repair Work Done U Type of Pump +� H.P. State Work Don i1 <br /> Well Destruction ❑ Well Diameter 1 3ealing Iseterial i Depth <br /> Depth l Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION ❑ DESTRUCTIONINo septic system permitted if public sewer is r <br /> available within 200 feet.) <br /> Installation will serve: Residence- -Commercial _ Other �J <br /> J` Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: f f Water table depth <br /> SEPTIC TANK ❑ Type/Mfg 1 Capacity No. Compartments <br /> PKG. TREATMENT PLT. Cl Method of Disposal <br /> i Distance to nearest: Well Foundation Property Line <br /> ' LEACHING_LINE Cl No. 8.Length of lines Total length/size <br /> r <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS It Depth l Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS D 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 cit ifles the following: "I certify that m 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 workmen's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I unify 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 Califor I <br /> The applicant at or I fogwir In ctispo ons. Complete drawing on reverse side. O� <br /> r Signed �� ' �� Title: ad1+(»r- Date: , 1 <br /> _ FOR EPARTMENT USE ONLY <br /> Application Accepted by w/` SL�,,t Date Area <br /> 7 <br /> Pit or Grout Inspeetion by Date Final Inspection by Date <br /> Additional Comments: _ <br /> 1 ' <br /> 1Ppllcant - Retu,= all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION-PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOR 2008, STOCKTON, CA 95201 <br /> FEE <br /> INFO OUNT DUE • AN OUNT REMrTTEO CASH RECEIVED BY ^ DATE PERM17 NO. <br /> fH 13-2 IREV.ri�Si 1 C+ 1 ,O '•l� l•F t `� I <br /> EN 14•le [ <br />