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APPLICATION FOR PERMIT <br /> 25 SAN `JOAQUIN COUNTY PUBLIC HEALTH 'SERVICES <br /> OENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (2b9)468-3420 <br /> r P O 'BOX 2009, STOCKTON, CA` 95201 <br /> t ]EXPIRES 1 YEAR FROliI DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made t'o San Joaquin County for a permit to construct and/or.installthe *cork herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 5I+9-and 862 and.the Rules and Regulations of San <br /> Joaquin'County Public Health'Serviees. <br /> Job Address City+ Lott Size/Acreage <br /> Owner.'s Name, Address { phone <br /> Contractor , +Address .._...,..,.,... <br /> [ License No. IV phone / z-10 <br /> TYPE OF WELL/PUMP: NEW WELL ❑'. L, WELL RE AGEMENT ❑ DESTRUCTION ❑ Out'of Service well ❑ <br /> PUMP INSTALLATION ❑ SY TEM REPAIR ❑" OTHER'©r' Monitoring well ❑ <br /> 1. <br /> DISTANCE TO NEAREST: SEPTIC TANK _ :SEWER LIN DISPOSAL FLD. PROP:'LINE ' <br /> FOUNDATION AGRIC RE WELL OTHER WELL PITS/SUMPS r <br /> ' INTENDED USE TYPE OF WEyh , <br /> � CONSTRUCTION SPECIFICATIONS <br /> C7 Industrial ❑ Open BottoManiacDia'. of Well.Excavation Dia:.of Well Casing <br /> Domestic/Private ❑ Gravel PackType of Casing— <br /> .0 Specifications <br /> I.1 Public 1..i otherDepth of Grout Sea! Type of Grout <br /> ,I ! Irrigation .Approx.DSurface-Saul Installed by <br /> Repair Work Done U' Type of Pump -''r State Work Done • <br /> f 's Well Destruction ❑ Well Diameter Seali 'Material V-Depth <br /> Depth Filler to`fel & Depth <br /> TYPE OF SEPTIC WORK:. NEW INSTALLATION I I . REPAIR/ADDI OND.ES RUCTION I I (No septic system permitted if public sewer is <br /> NU, a+I b.19 withig1200 feet <br /> Installation will serve: Residence Commercial her ,? <br /> Number of living units: Number,of bedrooms <br /> f <br /> i Character of soil to a depth of 3 feet: '- ,Water table'depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, ❑ + Method of Disposal <br /> pi t Distance to nearest: Well U 6oundation- ~Property Line <br /> ' { LEACHING LINE D No. 8 Length of lines r To I lengthoe <br /> .i FILTER BED ❑ Distance to nearest. Welt. ■ <br /> Foundatjon� Property Line <br /> f SEEPAGE PITS x I 1 Depth ire umber <br /> SUMPS C! Distance to nearest: Foundation X, Property Line <br /> '- DISPOSAL PONDS CI <br /> I hereby certify that I have prepared this applicanon and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and tegulations of the San Joaquin County <br /> Home owner or licensed a ent's signature certifies the following: <br /> g t} g: "I certify that in the performance of the work for which this permitls ssuad, l shalf.not <br /> employ anyperson in ouch manner as to become subject to workman's compensation laws of California."Contractor' hiring or subrcon(r�cting signature <br /> certifies the following: "I certify that in the performance of the work for which,.IN4 permit is issued, <br /> tion layws of California." I shall employ persons subjeot.to workman's compansa <br /> ?;4;_ <br /> The'appGcantust call fo all required inspections. Complete drawing on wtfafsa-side. 1, <br /> Signed X <br /> ._... ", . data: <br /> F R' DEPARTMENT USE ONLY', <br /> Application Accepted by ` r" "" v A"I <br /> re <br /> _.., -... r..,. <br /> Pit or Grout Inspsction-by ti Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant — Return all copies to: San Joaquin County Public Health .. <br /> Services, Environmental Health Permit/Services <br /> t 16oi E. Hazelton Ave., P 0 Box 2009, Stockton CA 95201 <br /> _ r <br /> FEE AMOUNT DUE AMDUNTREMITTED CK RECEIVED BY DATE PERMIT'ND, <br /> INFO r ASH <br /> =)As <br /> E. 14.201 , <br />