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I <br /> �- APPLICATION FOR PERMIT <br /> l SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-'3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> DRRI(il EXPIRES 1 YEAR FROM DATE ISSUED <br /> t (Complete in Triplicate) <br /> 1, t <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. <br /> I Job Address City Lot Size/Acreage I C <br /> JSJ <br /> ,, bwner'.a Name ` Add est <br /> ti ` •r _ _ _ _ Phone <br /> r Contractor, ddress License No. �`.ct �ov Phone <br /> '777€-OF,WELL/PUMP: NEW WELL ID WELL REPLACEMENT 17 DESTRUCTION ❑ Out of Service Well 0 <br /> i PUMP'INSTALLATION 0 SYSTEM REP © OTHER CJ Monitoring well <br /> yDl'STANCE TO NEAREST: SEPTIC.TANK r SEWE LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRI LT WELL OTHER WELL PITS/SUMPS <br /> f •{ <br /> ' IN7ENDf6-6SE TYPE OF,W�L"L PROBLEM A CQNSTRUCTION SPECIFICATIONS r <br /> F] Industrial , .ARD Open Botto O'M' eca ek Dia. of Well Excavation . b of Well Casing <br /> fF <br /> C] Domestic/Private Cl Gravel Pack`{`.. Tracy w '`-r,,J Type of Casing - -� Specifications <br /> I"1 Public Cl Other n Delta Depth of Grout Sea[ " k Type of Grout 6 <br /> �' l L <br /> F ' I I Irrigation — Approx. P. <br /> ,-'I l Eastern' ^. Surface Seal installed v, f ' <br /> Repair Work Done 0 Type'of,Pump :P, State Work Done \ <br /> Well Destruction R ❑ AWell Diameter <br /> Sealing Material & Depth <br /> `f 'p` `" Depth-� °�' _Filler Materiel&-Depth 'r '~" <br /> TYPE OVSEPTIC WORK: NEW INSTALLATION l I: R ,AIR/ADDITION { I DESTRUCTION 1-1-(Noseptic system permitted if public sewer is <br /> 1 t#. 1 I i available within feet.) <br /> E installation will serve: Residence— Commercial_ theer� 1� "- <br /> Number;af living units: Number of bedrooms g,.,.-- r <br /> Character of soil to a depth of 3 feet: Water table depth <br /> F e SEPTIC TANK. •µType/Mfg I Capacity No. Compartments'�' '� <br /> PKG, TREATMENT PLT. ❑ t fp.-��._ "-'—"Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> k LEACHING LINE ❑ No. & Length of lines Tota ti'gth/size r <br /> FILTER BED 11 r Distance to naaiesi: We <br /> I - <br /> SEEPAGE PITS l I Depth Siva _ umber " <br /> a SUMPS LI I Distance to nee est: Well Property Line r I <br /> DISPOSAL PONDS ❑ 3` q ; <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 Joaquiri,County S r <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,-1 shall not <br /> employ any person in such`manner as to become subject to workman's compensaiion 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 .vo'ikntsn's compansa- <br /> tion laws of California."r ` <br /> The applicant ust call for ired incoons. Complete drawing on reverse side. <br /> �- %:�i <br /> Signed f � Title: Date: _ <br /> * ,b FOR DEPARTIME.fITUSE ONL--Y! <br /> Application Aceepted by R ' ' « -date �J Area <br /> t <br /> Pit or Grout Inspection by l Datt4i /. Final-Inspection by Date <br /> 4- t /J <br /> Additional Comments: <br /> Applicant -Return all copies to: 'San Joaquin County Publii Healthy <br /> ! Services, Environmental-Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009,,°fStockton, CA 95201 V <br /> ` IEE AMOUNT DUE " AMOUNT REMITTED C <br /> FEE <br /> ASH RECEIVED BY DATE PERMIT'N0. <br /> ji Eli 13-24IREV.1/nsf Y �%0 <br /> [ilii EH 14.26 <br />