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APPLICATION FOR PERMIT <br /> - <br /> SAN40AQUIN COUNTY PUBLIC HEALTH SERVICES. <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ' P O BOX 2009,-'- STOCKTON; CA 95201 <br /> (209) -'468-3447 <br /> YEAR AOM DAZE %UM <br /> (Complete in Triplicate) <br /> t1 - <br /> Apylicatiow-is.hereby made to Baa Joaquin Canty for-a-permit Ak?'construct and/or install the work'herein described. Thia <br /> Lpplic;tion-is*'atade is Compliance with San Joaquin Coua4i0rdinance No.,549 and 1862 Lod the Rules and Regulations of-baa <br /> Joaquin County Public-health Services. <br /> Job Address 7 C. . ` .Ulor City5TCCGCT'dA1 Lot Size/Acreage• <br /> Qw�tsh Name. Address G TbGCiO Phone -IZ <br /> Coniraclot� eCf rte r Addresss�•M / License No.V rG��_ . Phone I <br /> TYPE OF WELL/PUMP: NEW WELL IN WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well :❑ <br /> PUMP INSTALLAT,IIO/N 13SYSTEM REPAIR C7 OTHER O Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK AV SEWER LINES DISPOSAL FLD.N1�_ PROP. LINE /d <br /> FOUNDATION /Q• — AGRICULTURE WELL &A— OTHER WELL1Y1� PITS/SUMPS <br /> !INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C1 Industrial "-'-' ' ❑ Open Bottom ❑Luntecs Dla. of Wel Excavation r Dia. of Well Caring15� Zr` <br /> Oerru�tit:/Private•._,, Gravel Pack ❑Ta g Specifications.SCR-_¢o._ <br /> ... .. Tracy Type of Corin UG. <br /> M Public ` to Other ❑Delta Depth of Grout Seal - Type of Grout Eti'" <br /> �Cr <br /> Irrigation Approx:'Depth ❑Eastern _ Surfice Soul Installed by N C <br /> Repair Work Done_ U Type of Pump M.P. Stat. work Done ._ <br /> We!I Destruction ❑ Well Dlameter sealing Material i Depth <br /> Depth Tiller Material i Depth <br /> TYP$,OF SEPTIC WORK: NEW'INSTALLATION❑ REPAIR/ADDITION 0 DESTRUCTION C1 (No sepric system permitted it public sewer is <br /> available within 200 lest.) <br /> Installation'riill serve. Residence_ COmmercial Other <br /> Number of living units: Number of bedrooms <br /> Character of $oli to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Typ./Mfg Capacity _ _ No. Compartments <br /> PKG.TREATMENT PLT.Q Method of Disposal <br /> Y : Distance to nearest: Wel Foundation Property Line <br /> LEACHING LINE 0 No. A Length of lines Total lengthlases <br /> FILTER BED Q Distance to nearest: Weil Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Cl Distance to nearest: Wall Foundation Property Line <br /> DISPOSAL PONOS ❑ <br /> I trereby cavity that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws,.and <br /> rules and reyulatlons of the San Joaquin County <br /> Home ownstor licensed agent's signature certifies the following: "1 oertily that In the performance of the work for which this permit is issued. I shall not <br /> employ any person in such'manner ar to become wl,j a to workman's compensation law$of California." Contractor's hiring or sub-contracting signature <br /> esrdfles the fQII0VA Q:"1 Certlty that in the performertaa of the work for which this permit is issued,I shall employ persons subject to workman, compensa• <br /> tlon laws of Califorrtla."_ . =.. ... -... .. ;. _-- <br /> The applicant t r all r ulred_ speCtiont. Complete drawing on avers* side. <br /> Signed Title:011 <br /> OJvsu - r Date: 3 <br /> FOR DEPAR SE ONLY <br /> Applicationccepted by Date 4as -�-3, <br /> Pit or Grout (t?speetlon by Date / gC/ <br /> Fines Inspection b Date <br /> Additional Comments: <br /> ApplicA4t - Return all copies tot BAN TOAQMN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONl1WAL HEALTH DIVISION PEAYIT/SERVICES <br /> 445 N SAtI JOAQUIN, P 0 SOX 5000, STOCKTON. CA 85201FEE �c !/ /� <br /> INFO AMOUNT DUE AMOUNT REMirrEO CASH RECEIVEDaY DATE vc IPIERMIT'NO.I'll-24 its 5?17 <br /> ,I'W <br /> EN,�•3a <br /> i <br />