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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC <br /> ENVIRONMENTAL HEALTH DIVISION <br /> VICES <br /> P O BOX 2009, STOCKTON, CA 95201 �' , /�/ fir`• ''� <br /> (209) 468--3447f ©y <br /> p04 <br /> (Complete in Triplicate) � T/��'9� L1'P' <br /> Application is hereby made to San Joaquin County for n �/�'y� �r' <br /> application is made in compliance with San J permit to construct and/or install the work herein descr94. <br /> JmQuin Count Publio Health Be ices 'oaquin County Ordinance No. 549 and 1862 and the Rules aad Aegulntiona of Sans <br /> Job Address <br /> City /Acreage <br /> LAU. <br /> Ow is Na _ "t <br /> I Address <br /> Phone <br /> ra for Address / ` <br /> Li <br /> TYPE OF WlrLL/PUMP: cense No. Phone / <br /> NE EL.L�O WELL/REPLAC ENT [l <br /> PUMP INSTALLATIONDESTRUCTION ❑ Out of Service Well <br /> DISTANCE TO NEAREST: SEPTICTANK C7 <br /> S <br /> f �r SYSTEM REPAIR C1 OTHER ❑ Monitoring Well i1 <br /> � SEWER L1NE5E <br /> FOUNDATION —~" DISPOSAL FLD' PROP. LINE <br />! —�— AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AAEA CONSTRUCTION SPECIFICATIONS <br /> f7 industrial ❑ Open Bottom ❑ Man teca <br /> Dia, of Well Excavation Dia.'o}Well Casing <br /> meauclPrivaoe ❑ Gravel Pack ❑ Tracy i T <br /> M Public tt Depth <br /> of Casing Specifications <br /> ' f-] Other ❑ Delta t Depth of Grout Seal <br /> GI 1rri0atiart Approx. e <br /> rn TYPa of Grout <br /> Repair Work Done U T I SuAace Soul installed by <br /> Yt�of PumState Work D <br /> Well Destruction ❑ Well DiameterSealing Material i DepthDepthFiller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW tNSTALLA I ❑ REPAIR/ADDITION LJ DESTRUCTION Ll No septic system permitted if public-sewer is <br /> Installation will servo: Residence_.__ Commercial�, Other available within 200 feet.) <br /> � .� <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: V <br /> SEPTIC TANK ❑ Typ*/Mfg water table depth <br /> PKG. TREATMENT PLT. C1 Capacity No. Compattments <br /> Method of Disposal ' <br /> Distance to nearest: Well <br /> Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of tines <br /> FILTER BED n Distance to nearest: Well Tonal length/size <br /> r r <br /> Foundation _ property Line _ r <br /> _ F <br /> SEEPAGE PITSpth <br /> I ! De <br /> Size ; <br /> SUMPS L] Distance to nearest: Wail Number <br /> DISPOSAL PONDS ❑ Foundation �� proPe►tY Line <br /> I hereby certify that I have prepared this application and that the work will lie done_in.•Ac}ordance with San Joaquin county ordinances, aceta laws, and <br /> rules and regulations of the San Joaquin County A <br /> Home owner or licensed agent's signature certifies the following; "I o rtify that in the <br /> employ an I p Performance of the wgrk }or which this permit is issued, l shall not <br /> P y e parson in such manner i to become subject i1 workmen's cam enaction laws of California," Contractor's hiring or sub-contracting signature j' <br /> canifisa the following; 'y certify that in the performance of the work for which thisnla is issue C anal. C to <br /> tion laws of California." __ permit.'_ � p y persons subject to workman's compansa- <br /> The applicant f r quired ins ions. o late r i <br /> &sever ids. <br /> Signed 47' / <br /> Titie: Date: f�� <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by , <br /> I f! � <br /> Pit or Grout Inspection by to Area � <br /> Date Final Inspection by �l <br /> Additional Comments: Dat <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 <br /> FEE AMOUNT DUE AMOUNT REMITTED. CK <br /> 1NF0 CASH RECEIVED BY DATE <br /> , ///f _ PERMIT'NO. <br />+ EM 13-241lIEV.1/ri Sl 1 i 4 <br /> EH i�.� lye <br /> T <br />