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.r. _a I <br /> APPLICATION FOR PERMIT <br /> ' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> DTMIT FX1iIRRS 1 YEAR `ROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application ie hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This r <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1562 and the Rules and Regulations of Sen <br /> Joaquin county, Public Health Services, c yy�� j� <br /> Job Address ` • �� t r "'�"F CitySJ& Lot size/Acreage <br /> Owner's NamejkA4 te_ I" vim- �> ales Address ftr7oo W' ;fir Jftg AA_ -- ._ Phone <br /> Contractor I Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT FIDESTRUCTION ❑ Out of Service Well ❑ "_ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER Mon ng <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PRO <br /> L C <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION <br /> n Industrial O Open Bottom ❑ Mania" Dia. of Well Excavation Dia. of Well Casing <br /> O Domestic/Private f1 Gravel Pack. ❑ Tracy Type of CasingSpecifications <br /> ❑ Public 1-1 Other 0 Delta Depth of Grout Seal AP Type of Grout <br /> G Irfioalion ^Approx. Depth ❑ Eastern Surface Soul Inslailed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction 0 Well Diameter Sealing Material i Depth <br /> _ Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION G (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial,.,,._. Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> -SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal -� <br /> Distance to nearest: Well Foundation Property Line ` <br /> LEACHING UNE ❑ No. & Length of lines Total length/size \ <br /> FILTER BED CI Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Site Number r <br /> SUMPS LI Distance to nearest: Well Foundation Property Line I � <br /> DISPOSAL PONDS ❑ <br /> I hereby cenify that I hove 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 Sart Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I cenify 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-contracting signature <br /> cenifies 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 California." <br /> The applicant must call for all required inspections. <br /> Complete drawing on reverse side. <br /> Signed S • �""—r�� Title: _y Date: <br /> OR EPARTiMENT USE ONLY <br /> Application Accepted by Date r G Area s <br /> Pit TeInspaction by ' Date Z- �� Final inspection by r-z U <br /> Additional Comments: `C]�a h�; �`e+eche�, cry. cin d 4 I,✓ e or.� _ <br /> I <br /> Applicant - Return all copies to: :SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> .ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 A� <br /> FEE AMOUNT DUE AMOUNT REMITTEp CK RECEIVED By DATE PERMIT NO. <br /> INFO CASH C <br /> . EH1��241REY. /MSS � <br /> f"114.26 r <br /> i <br />