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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PERMIT EXPIRES 1 YEAR MOM 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./^1 ,Ai <br /> Job Address 2 S_ El -2 O e) City aL61)Ctu Lott Size/Acreage -2/7 <br /> 7 n W'C?r <br /> Owner's Name �1) 1Z ls� ✓ Address EP5-O � V V Phone <br /> Contraclor G ry v<'J Address License No. Phone <br /> —TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ R_-0 Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DI FLD. PROP. LINE _ <br /> FOUNDATION AGRICULTURE WEL OTHER WELL PITS/SUMPS _ <br /> ` INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ lice Dia. of Well Excavation Dia. of Well Casing <br /> O Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> — <br /> M Public �Typs <br /> ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation . Depth ❑ Eastorn SuAace Saul Installed byRepair Work Donep H.P. State Work Dona — vJ <br /> Wall Deft n ❑ Wall Diameter Sealing Material i Depth D <br /> Filler Material L Depth lV <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION ❑ DESTRUCTION CI (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence �L. Commercial_ Other <br /> Number of living unite 4— Number of bedrooms f <br /> Character of soil to a depth of 3 feet: Water table depth 7 <br /> SEPTIC TANK ❑ .Type/Mfg Capacity O0 No. Compartments 2-, <br /> PKG. TREATMENT PLT. ❑ Method of Disposal P <br /> Distance to nearest: Welt QQ Foundation [/n / <br /> _L11� Property Lina 25-' <br /> r LEACHING LINE No. 8 Length of lines ,31Z=_ <br /> Total length/size �,��A�, <br /> FILTER BED 171 Distance to nearest: Well Z Foundation �� r Property Line 11c <br /> SEEPAGE PITS X11 Depth SireaX �a Number 2 — C) C <br /> SUMPS Rii Distance to nearest: Well �O Foun ion -7Property Lina S <br /> DISPOSAL PONDS O <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 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 applicant ust call for al required inspection Complete drawing on reverse side. <br /> Spn ✓ /?_11 ' Title: ��i1 �r.L72i Data: <br /> _ ',I{A4 R PARTMENT USE ONLY <br /> APPlicatio AceePtad by k s"', � Date a . <br /> Pit or Grout Inspection by Date Final Inspection by Osts <br /> Additional Comments: <br /> Applicant - Return all copies to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> FEE INFO [�Tp�UE A/MO�UNNT RESM�ITTED CASH CK RECC/CEIIVEO BY OATE PERMIT NO. <br /> EH 11.7E IREV.,r.si 17; <br /> (�7rUV /TL-) 9-13-9� (V-,2yV� <br /> EH 161e <br />