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4 <br /> APPLICATION FOR PERMIT(-' <br /> SAN -.IOAQUIN COUNTY PUBLIC HEALTH ERVICES <br /> HNVIRONNmTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468•-3420 <br /> P O -BOX 2009, STOCKTON, CA 95201 i <br /> PERMIT EXPIRES I XUR FROM DATE ISSUED <br /> i <br /> (Complete, ia Triplicate) <br /> Application is hereby made.to San Joaquin County for a Permit to construct and/or install the work herein described. ThiSans <br /> spplieation is made in compliance with San Joaquin County ordinance Ro. 549 and 2862 and the Rules and Regula <br /> tions Joaquin County Public Health Services. <br /> ,jam <br /> Lk I `1 City �� Lot Size/Acreage <br /> Job Address <br /> 's Name <br /> L <br /> Owner <br /> Address ` Phone <br /> f . ; . License No.r.5� {%51 1P%5 Phone t) <br /> s ass <br /> Contract <br /> TYPOF WELL/PUMP: NEW WELL WELL REPLACEMENT C.1DESTRUCTION ❑,r Out of Service dell <br /> WELL/PUMP: C1 L� <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ a,���R,rt�OTliEA up Monitoring hell <br /> DISTANCE TO NEAREST: SEPTIC TANK `SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE'OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i <br /> L Industrial 0 Open Bottom 0 IMantecs „a b0ia. of Wall Excavation Dia. of Weil Casing <br /> n Domestic/Private ❑ Gravel Pack -' (3 Tracy 0 r"Type of Casing Specifications <br /> Il Public n Other n Dslta b"Depth of Grout Seal Type of Grou <br /> I I Irrigation -.Approx. Depth I I Eastern - Surfatce Seal Installed by <br /> Repair Work Done. U Tvlw of Pump'. H.P. Stat Work i s <br /> WeH Destruction` O WeH'Oian+atar Sealing Material k Depth <br /> r_. Filler Material ! Depth ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I ,REPAIR/AOOITION I I DESTRUCTION I I {No septic system permitted if public sewer is i <br /> available within 200 feet.) <br /> Installation will serve: Residence_} Commercial.�^ Other <br /> Numbs of living units: Number'of bedrooms ' <br /> Character of soft to a depth of 3 too: Water table depth <br /> SEPTIC TANK. %ri r; 0. ;Xvpe/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. .- „ `c*,J Method of Disposal <br /> ,. 4+ #.- <br /> < Distance to nearow Well Foundation Property Line <br /> "M YMP14 <br /> LEACHING LINE. 5r. 0-'No:i Length of fines � � Total length/size <br /> FILTER BED . -if(3 Distance to newest: Wed Foundation Property Line 1 vED 1 <br /> A nnLl <br /> F• �. �.. <br /> SEEPAGE PITS -" I I Depth <br /> Size Number Weil <br /> (JfN 00 <br /> SUMPS .. L�i_ i,Distance to merest" , H Foundation Pr LPAJ UNC <br /> �,. .. NVIROH SERV <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 ordi Q,44m, an <br /> rules and regulations of the San Josquin'Ccnnty <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 Caiifornia.".Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify that in the padomssrtce of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of Calltomis." <br /> The s for. ind inspections.Complete drawing on reverse side. �] Q <br /> Signed cele: �)-rl 1 r Date: <br /> 17- <br /> F EPARTMENT USE ONLY <br /> Appiication Accepted by Date Z Area c� Q <br /> Pk or Grout Inspection by Date Final Inspection by Date ` <br /> Additional Comments: i� <br /> Applicant - Return all copies to: San Joaquin County Public Health Services 2q,K/ eST <br /> Environmental Health Permit/Services <br /> 445 A San Joaquin, P O Hoa 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED x A RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH00 <br /> . EH <br /> 4121 <br /> EN 14-M a !!�/�J <br />