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APPLICATION <br /> JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN"JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> ,i <br /> ` r PERMIT EgPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County y for a permit to construct and/or install the work herein described. This <br /> f application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of:San <br /> Joaquin County Public Health Services. <br /> Job Address City Lot Size/Acreage _ <br /> Owner's Name Address {V <br /> ane Q . <br /> Contractor- __ Address License No. Phone C'�V <br /> TYPE OF WELL/PUMN!W WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Ve11 ❑ �1 <br /> PUSTALLATfON EJ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well <br /> DISTANCE TO NEAREST; SEPTIC TA SEWER LINESDISPOSAL FLD. <br /> PROP. ,i <br /> LINE \ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEMI STRUCTIDN SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Ma Dra. ell Excavation_ TI <br /> Dia. of Well Casing <br /> f.l Domestic/Private 0 Gravel Pack Tracy Type of Casing_ Specifications cs <br /> I'I Public CI Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation pprox. Depth 11 Eastern Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. State Work Done„ ! <br /> Well Destro ' n x �p Well Diameter . Sealing Material & Depth <br /> -Depth Filler Material & Depth .� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ! I REPAIRIADDITION i I DESTRUCTION {No Septic system ni <br /> 'i. P Y permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence; Commercial^_ Other <br /> Number of living units: Number of bedrooms j <br /> Character of sail to a depth of 3 feet: + j <br /> ..Water table depth a <br /> SEPTIC TANK ❑ Type-1"Mfg - Capacity No. Compartments ] . <br /> PKG. TREATMENT PLT. Ll .l Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> Tota! length/size <br /> FILTER BED ❑ Distance to nearst: `Well Foundation Property Line <br /> SEEPAGE PITS I I beplh Size Number <br /> SUMPS LI Distance to nearest: Well Foundation <br /> DISPOSAL PONDS a❑ Property Line <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 certifies the following: I certify that in the <br /> employ an �� Y performance of the work for which this permit is issued, I shall not <br /> p y y person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies 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." Y <br /> The applicant ust call for all r uired inspections. Complete drawing on reverse side, ' s <br /> Signed X r�t <br /> Title W!7 f-... Dat6T--J , I <br /> R D RTMENT USE ONLY <br /> Application Accepted by +' Date___. <br /> Area <br /> Pit or Grout Inspection by Date - Final,Inspection by <br /> Date+� <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> it 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 1 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED By DATE PERMIT'NO. <br /> . -- ! <br /> . EH 13-24[REV.Finn y ' <br /> EH 14.26 ZL�7 ��vfSoS <br />