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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 /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <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 vith San Joaquin County Ordinance No. 549 and 1962 and .the Rules and Regulations of San <br /> Joaquin Couy)y,Pstbllic Healt��h//services. <br /> lobAddross a !/rr�f/77lY.�+ /fit/ Cityrr`&h �� p Lot Size/Acreage <br /> wner's Name Vie-1 A 4V f` Address Otb "p't/'t° Phone <br /> contractor �Da&j fftdress _ .U10 FK tat CJI'_License No.��Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEW R LINES DISPOSAL FLD. PROP. LINE I <br /> FOUNDATION A (CULTURE WELL OTHER WELL PITS/SUMPS \ <br /> INTENDED USE TYPE OF WELL PRO AREA CONSTRUCTION SPECIFICATIONS <br /> ,0 Industrial ❑ Open Bottom ❑ M� to Dia. of Well Excavation Dia. of Well Casing O <br /> CI Domestic/Private ❑ Gravel Pack; ❑ Tracy Type of Casing_ Specilicationa <br /> I'l Pubtic n Other .-fl Delta pth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth I I Eastern Surface.Seal Installed by <br /> Repair Work Done LJ Type of Pump H.P. State Work Done <br /> Well Destruction ❑. , Well Diameter Sealing Material i.Depth <br /> Depth Tiller Material i Depth <br /> TFFILTER <br /> F SEPTIC WORK; NEW INSTALLATIO REPAIR/ADDITION ( I DESTRUCTIO INo septic system permined it public sewer is <br /> available within 200 feet.) C <br /> lation will serve: Residence� Commercial Other l <br /> er of living units: Number of bedrooms x <br /> cter of soil to a depth of 3 feet: Water table depth <br /> TANK. 0 Type/Mfg Capacity No. Compartments <br /> REATMENT PLT. ❑ L Method of Disposal <br /> Distance to nearest: Well( a Foundation �� Property Line <br /> NG LINE ❑ No. 6 Length of lines Total length/size �ICit <br /> BED 0 Distance to nearest: Well Foundation � Property Line <br /> .E-PITS I1 Depth Size Number <br /> LI Distance to nearest: Wall Foundation Property Line <br /> AL PONDS ❑ <br /> e 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 a lations 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-cohtracting signature <br /> certifies 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 Califomia." <br /> The applicant must call for MI required inspections. Complete drawing on ieverse side. �+ <br /> Signed X Lp, + Title: Date' �. <br /> I <br /> ate, V' 11 ROR DEPARTMENT /BE ONLY <br /> :; <br /> Application Accepted by ` _ Data Area <br /> i <br /> Pit or Grout Inspection by lots Final Inspection b Doti& <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, O Box 2009, Stkn, CA 95201 <br /> FEE OUNT DUE AMOUNT REMITTED RECEIVED BYD E PERMIT'NO. <br /> INFO <br /> L <br /> . PN 1�•241rtEV.l�Mai �/ �� �� ti� <br /> IN 14Za <br /> _4 <br />