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= r _ z <br /> MIN <br /> w:0 s r <br /> r S. <br /> - <br /> ":' <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICA <br /> ENVIRONUENTAL HEALTH DIVISION P, <br /> 1601 E. HAZELTON AVE. , ,PHONE (209)468-342Q <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> A <br /> f� (Complete in Triplicate) • ;: .., ` <br /> .tpplication is hereby bade to Sen Joaquin County far a permit to construct and/or ins <br /> application is wade In compllanee TMitb Sea Joaquin County Ordlo&nes 11tall the vrork0. 54 and 1862 tad the Rules r lhed' This <br /> Joaqula County Publicc,Heallltth services. gY.d�R a of San <br /> Job Address 70�+ City Lot Site/Acreage <br /> Ownsr'a Name _ Address <br /> t t ---T <br /> ,y Phone 1 t, <br /> Can S 't^ti Licence NO,g~louu <br /> TYPE OF WELL/PUMP: �0° <br /> NEW WELL WELL REPLACEMENT 0 OESTRUCTION ❑Out of Service Veli O <br /> PUMP INSTAL ON SYSTEM RE AI ❑ 0TH R ❑ xoaitorinng Yell <br /> DISTANCE TO NEAREST: SEPTIC TANK t� SEWER LINES �Q DISPOSAL FLD. r0 fPR(1P.LINE 00+y,� <br /> - FOUNDATION � AGRICULTURE WELL"f M&OTHER WELL.tpI'S/SUMPS I�171 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Induatnal ❑Open Bottom M <br /> Q Tris eu via.of Will Excavation_ it 04.of WON Caning <br /> 11 Oomesue/Private 1) Gravel Pack p Troy Type of Casirvlt G Specifications_ <br /> I'I Pubtic IxOlhar Oel4 Depth of Grout Seal 1® T!� <br /> t-1; 'rte/"/ - Type o}Grpu <br /> Approa.Depth I I Eastern SuAau Sero InataGad by�� <br /> Repair Wait Dons 0 Type of Pump H.P. Slate Wort Done <br /> WON Destruct= ❑ WON Oiartwlsr Seallns Material i Depth <br /> Depth` Y11ler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW tNSTALLATlON I I RCPAIR/AODITION I I DESTRUCTION 1 I iNo%stint system permuted if pubbe sower is <br /> Instails6an wall serve: Residence_ C ava+lable wrthin 200 faet.l <br /> onunere4f� Other <br /> Number of living units, Number of bedrooms <br /> Character of%oil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Typs/Mfg Wrist table depth <br /> � - PKG..TP:.;rfMEHT PLT.Q Capecrty-�--- No.Compartments <br /> Method 01 Oisposal <br /> u <br /> Distance to nrereat: WON Foundation _ Property Luve <br /> LEACHING LINE ❑ N0.6 Length of final Total kngthlsizs <br /> f FILTER BED fl Distance to nsareat: WallFoundation <br /> �Property Lirvs <br /> SEEPAGE PITS 11 Lapth Sire <br /> Number <br /> SUMPS Ll Distance to naereat: Well FounNtsan <br /> DISPOSAL PONOS ❑ "`�-�Prop"L'^e <br /> I hereby eemfy that I hew prepared thio application and that the work vhnA be done in■:eordance with San Joaquin county ordmanrea,slate laws. <br /> and <br /> rules and ragufalions of lia San Joaquln County <br /> Home owner or licsnaed sgsm's argnature c ntEias the 1040wing:"I csmfy that in the perfetmanea of the work for which this permit is issued,J shall not <br /> employ anv person in such marina,as to b_v subpact 10 workman's compenal*m!aura of Calif <br /> .xrnia."Con{raCiOra hiring W sulxonttsuad. signature <br /> tannin the Nlowing:"I cattily that in the Pa+fortnartce of the work for which this permit la iaaued,I thou sm <br /> � tion laws of CaGfornta." pc`/persona sub]Sc:-0 workman's compenaa- <br /> yi The apoksn t Cay 1 ar t <br /> equirsd Inapec)ions.Complels drawing on rawna aids. <br /> r <br /> Signed x /s.�./ n / <br /> ...L,�...,, Title: <br /> - 'R DEPARTMENT USE ONLY <br /> {1 Application Accliptall b <br /> J _Oats �3 D Area <br /> Pit or Grout fnepection by Oate <br /> -- - ---- - --_T_ -__- -------_- Final Inspection by <br /> - --- -- Data------ <br /> Additional <br /> atelAdditional Comments: <br /> ApDllcaat - Return all ccgiea tot 'San Joaquin County Publle Heslth <br /> Services, ffbviromental Health Permit/Serrices <br /> 1 1601 S. HAselton Ave., P 0 Sia 2009. Stockton, CA 95201 <br /> ��.. FEE AMviJNT DUE���CK INFO flECEPlED 0Y DATE PERMIT NO. <br /> E1111N rREV.nrafF 3.5 p <br />