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s � <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> PSNVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERIICIT BUIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) ; <br /> Application is hereby mede,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application ie made in cowliance with Ban Joaquin County Ordinance Ho. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> is <br /> Job Address ��(Dl icily of Size/Acreage <br /> War's Na a dress PhoneQU� i <br /> ntYbct"or wytiss <br /> Aide No, Phone' <br /> TYPE OF WELL/PUMP: NEW. ..L ❑ WELL REPLACEf,AEN7 DESTRUCTION ❑ Out of Service Well ❑ <br /> �' PUMP-INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Nonitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK ' —_ SEWER LINES DISPOSAL FLD. PROP. LINE 101 <br /> w FOUNDATION ~)4GRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE F-WELL <br /> PROBLEM AREA�CONSTRUCTION SPECIFICATIONS <br /> `0�dustrial ❑ Open Bottom "�Maniacs Dia.oftiWell Excavation Dia. of Well Casing <br /> 11.1 <br /> �FB0m stic/Private ❑ Gravel Pack ❑ acy„ Type of Ca'sin�gg— Specifications <br /> /f"1 Public L-1 Other ' ' n Delta Depth of GroutASeal Type of Gr 1 } <br /> � rrigatian —.Approx. Oap l astern ;Surface Seul Insta ed by <br /> Repair Work Done U Type of Pu H.P State Work Don v; <br /> Will Destruction ,O. Well Diameter7 r Sealing Mateiial i Depth <br /> f 4-Depth __ I I. . . biller Material Depth ■ <br /> 1 <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 111No septic system permitted if public sewei is. <br /> ( Fw available within 200 feet.l <br /> I `'1nstallation will serve: Residence_ Commercial_ Other <br /> �r t ' <br /> .� Number of living units: Number of bedrooms \\ii <br /> i Charades of sail-to.a,dspth-of-3=fest:-- Water tabis depth <br /> t !SEPTIC TANK. #. : ❑ Typi/Mfg Capacity No. Compartments <br /> PKG4 R TREATMENT PLT. G7"� r E ! <br /> r i Method of Disposal m <br /> Distance to nearest: Well Foundation Property Line . r <br /> I i i <br /> LEACHING-EINE ;❑ N&Length of lines Total length/size <br /> FILTER BED C1 Distance to nearest: Wall Foundation Property'Line , <br /> SEEPAGE PITS j I I Depth ° Sisa _ Number _ <br /> SUMPS LI Distance to nearest: Well Foundation s Property Line ,L4 <br /> DISPOSAL PONDS ❑ <br />' I-hereby-certify Ihot_I.hm prepared this application and that the work will 4e done int:accordance with-San:4p quin county ordinances, state laws, and <br /> rules and regulations of the Sen"Joaquin CoiZty - ` <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit isiissued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's Hiring ovsiub-contracting signature <br /> certifies the following:"Ithat in the performance of the work for which thispermit is issued, I shall employ persons sub'acCtovn`orkmsn's compensation laws of ifornia.The appal st callquir inspections. Complete drawing on raver s e. <br /> Signed Title': Date:, , <br /> a- OR DEPARTMENT USE ONLY i <br /> Application Accepted by •vk- Data SX- 1 Z-- Area ---� � <br /> Pit or Grout Inspection by Date Final Inspection byA­C9 Data <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> { Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 ` <br /> CK 9 <br /> INFOL <br /> FEEOUNT DUE AMOUNT REMITTED CASH RECEIVED 9Y DATE "PERMIT*NM <br />. EH 17-71(REV.,ins) P �e 0 V '1 �+Vr�L r�� � <br /> EH 14-M <br />