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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES r <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468--3420 <br /> I - P 0 BOX 2009, STOCKTON, CA 95201 1� <br /> BRUIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to SL Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in complianbe with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. AJ�h,,� �G <br /> Job Address ! „/ Lot Size/Acreage <br /> Owne(s Name G t 6 * Address SG S -__ Phone <br /> t i ' ` ' ._r <br /> ao <br /> t <br /> Con lractor � ,�r<-c�' -- Address License No. Phone _2� <br /> ` TYPE OF WELL/PUMP: INEW,WELL © WELL REPLACEMENT C7 DESTRUCTION-0 Out of Service Well 0 <br /> PUMP INSTALLATION ❑, SYSTEM REPAIR ❑ " "OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD._ PROP, LINE <br /> . FOUNDATION AGRICULTURE-WELL, OTHER WELL PITS/SUMPS <br /> UNTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> j n industrial ❑ Open Bottom C7 Mantec'a i Dia. of Well Excavation Dia. of Well Casing <br /> I CI Domestic/Private ❑ Gravel Pack x-❑ Tracy # -Type of Casing ` Specifications <br /> 1'1 Public {1 011ier:=P.. ;Y. .❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _.Approx. Depth J-) Eastern n Sufface Seal installed by <br /> Repair Work Done ❑ Type of Pump � H:P. Stare Work Done _ <br /> Sealing Material & Depth <br /> Well Destruction ❑ -Well Diameter ' i , "V <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR?ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is [n <br /> available within 200 feet.) <br /> i <br /> Installation will,serve: -Rasidence ::Commerclt+l = Other <br /> i, l Numaer,of living units:__J_ Number of bedrooms <br /> Character of soil to a dept f 3 feet: f� ^i"� f - " Water,table depth <br /> SEPTIC TANK ! ype/Mig ! Capacity— n-_ _- No. Compartments 21. <br /> PKG. TREATMENT PLT. ❑ F Method of Disposal 11-1 <br /> [ Distance to nearest: Well .Foundatianl 1 .2 Pr p rty Line <br /> i•u- l t <br /> i LEACHING LINE No. & Length of lines s r(3 r Total length/size <br /> S <br /> FILTER BED E) Distance to nearest: Well­'ir_�_ Foundations Property Line d <br /> ( SEEPAGE PITS Depth'l ac; Size 1- _Number <br /> 'ior <br /> SUMPS L l Distance to nearest: Well es Foundation Y�s�J Property Line k <br /> I E DISPOSAL PONDS ❑ l 1 <br /> I hereby certify that I have prepared alis application and that the work will be done in accordance with San JoaquFg county ordinances, state laws, and <br /> i rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following, 'tl:certify that in the performance of the work for which this permit is issued, I shalt not <br /> employ any person in such manner as io become subject to wotkrrian's compensation laws of California." Contractor's hiring or sub contracting 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 /> r tion laws of California." <br /> The applicant must call for It r wired inspections. Complete drawing on reverse side. x <br /> 1 t <br /> Signed Title: � Date: <br /> FOR DEPAftTfMENT USE ONLY <br /> rr <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date i! h IN <br /> ! Additional Comments: <br /> t <br /> Applicant — Return allcopiesto: San .To win County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> I FEE <br /> i INFO /A.MOUNT AVE AMOUNT REMITTED CASH RECEIVED 9Y DATE <br /> f�/� PRERMI7'N8. <br /> . EH 13-24IREv.1/aw J, IIY I /`� r/- �,,y <br /> i/ EH A-20 I - - <br />