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APDL T CATT ON FOR PIiRlld I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES -7151 t <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 'P O BOX 2009, STOCKTON, CA 95201 , <br /> I (209) 468-3447 <br /> NOW <br /> PERMIT EMIRFS 1 YEAR OROM 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 ccnpliance with San Joaquin County Ordinance No. 5119 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> 1 <br /> Job Address _ �1 d -- - City Lot Size/Acreage 4 - <br /> `L l� <br /> Owners Name !e- A JAk 7Ll (6q <br /> pejAddress q L ���� Phone <br /> s rye. ! <br /> -Contracto( , 1 Address � Cvf t� _. License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well Gl <br /> PUMP INST { TION 0 -SYSTEM REPAIR ❑ OTHER ❑ Storing well <br /> DISTANCE TO NEAREST: SEPTIC TANK f SEWER LINES DISPOSAL FLO PROP. LINE <br /> FOUNDATION ICULTURE WELL ELL PITS/SUMPS T <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CTION SPECIFICATIONS <br /> M Industrial ❑ Open Bottom ❑ Ma Dia. o I Excavation Dia. of Well Casing <br /> L) Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications <br /> [ Public i l ❑ Delta Depth of Grout Seal _ _ Type of Grout <br /> CI Irrigation �.,Approx. Depth ❑ Eastern Surface Seal-Installed by (� <br /> Repair Work Done U Type of Pump # H.P. _ State Work Don U i1 <br /> Walt Destruction ❑ Well Diameter f SealSng l4aterlal i Depth <br /> Depth Filler Material i Depth pi <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION CT DESTRUCTION (No septic system permitted if public sewer is r <br /> available within 200 feet.] <br /> Ir 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 /> f SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments D <br /> { PKG. TREATMENT PLT. ❑ . Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING.LINE L"1 No. &.Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Welt Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 Joaquin County <br /> Home owner or licensed agent's signature cenifies 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 workmen's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> cenifiss the following: "I cenify 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 Califor ' <br /> The applicant at I or all requir ins ctipe ons. Complete drawing on reverse side. <br /> X Signed 7���--" Title: __ CC) + . ■A Date: <br /> FOR EPARTMENT USE ONLY <br /> �v�- <br /> Application Accepted by _ -- 4 ._ Date __ .w Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION-PERHIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 85201 <br /> FEE INFO OUNT DUE ` A OUNT REWTTEO GASH RECEIVED BY DATE PERMIT NO. <br /> . CH 13-241pEV.r/nsi Ll.'� C 1 �`(-ql <br /> EH 9{•2e <br />