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APPLICATION FOR PERMI S� <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOR 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES-1 YEAR FROM 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 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 0 rd f4 Ve_J Citdj_--_U.C.Lof Size/Acreage <br /> �n u I � t�,p f_` ' <br /> �1Ld ' ! L{ i D j 0 rD y r Phone 'l <br /> Owner's Name. �f"A.J i 1 '�rAddress � .� -- <br /> Contractor ►1 'RS=�C Address License No, Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service well 0 <br /> PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER errttoring Well <br /> DISTANCE SEPTIC TANK SEWER LINES DISPOSA PROP. LINE <br /> FOU AGRICULTURE WELL ER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PRO EA RUCTION SPECIFICATIONS <br /> 0 Industrial 0 Open Bottom ❑ Ma Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private Ll Gravel Pack Tracy Type of Casl Specifications O <br /> I'I Public Ci Other 171 Delta Depth of Grout Seal Type of Grout <br /> i I Irrigation .. pprox. Depth I I Eastern Surface Saw installed by r <br /> Repair Work Done Type of Pump . H.P. $tate Work Done ` l! <br /> Well Destruc- O Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION ! I DESTRUCTION 'iNo septic system permitted if public sewer is D <br /> available within 200 feet,) 5 <br /> installation will serve: Residence_ Commercial Other <br /> Number of living units: Number of bedrooms <br /> �. <br /> IN V. <br /> y e�ff F Capacity No. tableer <br /> Compartments <br /> is <br /> PSIR <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Permit may have exp iNd.W In t: Well Foundation Property Line <br /> pEA,`Hl Ll 1 Nod+.}&, en t o Ines Total length/size <br /> yrtiygonm a1 EIR�ttl,Di9iSi9Qt: Well Foundation Property Line <br /> t <br /> SEEPAGE PITS l I Depth Size _ Number <br /> SUMPS Cl 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 i <br /> Home owner or licensed agent's signature certifies 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 workman's compensation laws of California." Contractor's hiring or subcontracting 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." <br /> The appli t st calkfr all r red ' ions.Zi:�Titls: <br /> awing on v rse side. <br /> �Slgned lw� Date: /X/4:1) <br /> ,\S <br /> 77 <br /> DRTMENT USE ONLY Aplication Accepted byZ, Phfi11- Date "r t^a� 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 <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO -� • ' CASH <br /> • EH 17.24IREV.+in51 ` eL1 ,t� ] ,meg4 W � ,��41 N <br /> tiH 14-Ze L ���ttt W 111 l <br />