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APPLICATION FOR PERMIT <br /> a. <br /> SAN JOAQUIN COUNTY. pUBLIC HEALTH SEIRVICES <br /> ENVIRONMENTAL HEALTH DIVISION • <br /> 445 N SAN JOAQUIN, PH0NE. (209)4ib8-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERM T E%PIRES <br /> 'FAR. FROM -PALE__ S <br /> (COmplete in Triplicate) <br /> Application is hereby made.to San Joaquin County for e <br /> application is made in OccoplHealth <br /> Sere with Baa Joaquin County prdinance No Sbg endand/o1862saad theeRuieb andeRegulatioa of Sans <br /> Joaquin County Public Health Services. <br /> Job Add►essa . t S� ^-e <br /> ity-% Lot Size/Acreage <br /> -¢. r l u� K RSSaog c? W . <br /> Owner's Name z° l N , Address S � <br /> r n Phone <br /> dress- ' i - .�,� _ _ � <br /> TYPE OF WELL/PUMP: � _ A -`�Licerrse-No;q- Phone��q`� <br /> NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION Out of Service He11 Cl <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR L-1 , OTHER ❑ Monitoring Hell n <br /> DISTANCE CE TO NEAREST: SEPTIC TANK_-�- SEWER LINES <br /> FOUNDATION _ _ DISPOSAL FLO. PROP. LINE <br /> -- _ AGRICULTURE WELL ----OTHER WELL-- - --SPIT /.SUMP_S- r <br /> INTENDED USE TYPE OF WELL , PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial ❑ Open Bottom ❑ Mane Dia. of Well Excavation Uh e <br /> C7 Domestic/Private ❑ Gravel Pack Dia. of Well Casing f <br /> CJ.Tracy +Type of Casing---,--. S a <br /> t'I Pyrbtic Cl Other .- Specifications i <br /> Cl Delta depth of Grout Seal n <br /> I I Irrigation -.Approx. Depth I I Eastern � � Ype ° rout ,_yv <br /> Repair Work Done' U T Surface Saul Installed b Q <br /> YPa of Pump ---�_.. H.P. <br /> Well Destruction ❑ Well Diameter _` Sealing lfateria.l i,Depth <br /> Depth <br /> Filler Material i.Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I 1 {No septic system 1 V <br /> s , <br /> permitted if public sewer is <br /> Installation will serve. Residence Commercial F available within feet.) <br /> Other_____ - p q its <br /> Number of living units: Number of bedrooms A ` V :� ( S <br /> Character of sdd to■ 1tti Up <br /> ; <br /> depth of 3 fast: d/&1. <br /> SEPTIC TANK ❑ Ty*/Mfg a r a depth <br /> Capacity No. Com rt nts f <br /> � �sal <br /> Distance to nearest:, Well Foundation <br /> Property Line , f <br /> LEACHING LINE 'Ll No. 6 Length of lines <br /> FILTER SEDTotal length/size <br /> [a" Distance to nearest: Wall Foundation <br /> k --��•Property Line <br /> SEEPAGE PITS I I "Depth -.Size <br /> SUMPS Number' <br /> Ll Distance to nearest: Well 3 <br /> DISPOSAL PONDS ❑ Foundation Property Line <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 Sen Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which thin permit is issued. I shell not <br /> employ any person in such manner as to become subject to workman's compensation law$of California." Contractor's hiringor sub contractin <br /> certifies the fodowi w � pe <br /> tion lawn of olowi California."I certify that in the performance of the work for which this permit is issued, I shalt am le g signature <br /> p y persons rubjOct to workman's compensa- a <br /> Thea <br /> applicant must Gall f all req 'ed in l coons. Complete drawing on reverse side. s. <br /> Sip e t 7 <br /> Title: Date: s <br /> 1 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by C E C ; <br /> i Date Area a Z c..) f <br /> Pit or G out inspection by � J`�� <br /> Date Final Inspection by <br /> Additional Comments, °' Dalg <br /> Applicant - Return all copie a: San Joaquin County Public Health Services <br /> .1\ �� Environmental Health Permit/Services i <br /> t �11./J 445.N'+San Joaquin; P O Box 2009, Stkn, CA 95201 <br /> I FEE <br /> INFO AMOUNT ptlE AMOUNT REMITTED CK RECEIVED BY <br /> CASH HATE PERMIT"NO, <br /> 3 <br /> EM 1Y?♦tREV.i/w S! yw1fb I,u° '1 <br /> EH 11.20 &0, 0 1D <br /> -h � <br />