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APPLICATION FOR PER IT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ESVIRONUMTAL HEALTH DIVISION {, <br /> P O BOX 20091, STOWON, CA:95201 . TIml <br /> (208) 468--3447 <br /> 4 <br /> k=11 E%PIRES 1 YEAR r _PA.n -1§jJUED <br /> (Complete In Triplicate) <br /> Appllcatioa is hereby made to &w Joaquin County for a permit to conatruct mWor install the work herein described. This <br /> application i• code In compliance with San Joaquin County Ordinance No. 549 =4 180 and the Rules and Regulations of San <br /> Joaquin Couutty�Public Health Services. <br /> ,lob Address _ +s' � � F Eu x�� .: ._ _. . CttyT;�� Lot Size/Acreage <br /> Owner's Name E'�E1 R�l . G� t %)MV , Address Phone P134> �C <br /> Contractor L eAc- Address_ Lkense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL.REPLACEMENT © DESTRUCTION ❑ Out of Service Well D <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR a OTHER O Monitoring Well � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑Open Bottom 17 Mantace Dia. of Well Excavation Dia. of Well Casing <br /> U DorneestielPrivate Q Gravel Pack © Tracy Type of Casing Specifications <br /> M Public 1-1 Other U Delta Depth of Grout Seat Type of Grout <br /> EI irrigation <br /> —Approx. Depth. ❑ Eastern Surface Seal Installdd by """ <br /> Repair Work Cons U Type of.Pump H.P. State Work Dors_ <br /> Wall Destmafttt . O Wall Diameter 14 Material.i Depth <br /> Depth Piller Material A Depth <br /> TYPE OF SEPTIC WORK: NEW"INSTARLATLOaI fiEPAlff/ADDITION Li DESTRUCTION WoSeptic system permitted it public sewer is <br /> W40"Within 200 feet.) <br /> Installation will serve: Residence;�Cormrtarciaf " Other <br /> Number of firing units: Number of bedrooms 3 <br /> Character of soil to a depth of 3 fest: Water table depth 2 <br /> SEPTIC TANK. 0 TypelfVtfgCapacity ZNo. Compartments <br /> PXG. TREATMENT PLT.ClMethod of Disposal <br /> Distance to nearest: Web L/ Foundation. Property Line . <br /> LEACHING LINE 6[ No. b.Length of fines- � Total wngthisii <br /> FILTER BED n Distance to nearest: Wen �$� Foundation Property Line <br /> SEEPAGE PITS I ] Depth Sive Number <br /> SUMPS Ll Distance to nearest: Wan Foundation Property Liana <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances. state tams, and, <br /> rules and regulations of the San Joaquin couaty <br /> Home owner or licensed sipm's signature certifies the following: "t certify that In the performance of the work for which this permit Is.issued. i$hail not <br /> employ any parson in such manner as to become subject to workman's compensation Is"of Cardornia."Contractors!tiring or Sub-contracting signature <br /> certifies the fosowing:"I certify that in the parformarnce of the work for which this permit is issued.t shall employ persons subject to workman's compartsa- <br /> tion laws of California." <br /> I The applicant rrjpst call for 4 required Complete drawing an reverse side_ �7 <br />!� <br /> Signed Y 7 - .� C` Ti+tee: __ !f�///ref -- Date: / <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comrnents: <br /> Applicant - Ratusn all copies to: "N JOAWIlm COUnTy p=Llc ==LTH S>MtVIczs <br /> 9XVISOttMtit NAL NFALTH DIVISION PERMIT/SERVICES <br /> 448 H SAH JOAQUIN, P O SQA 2009. STOCKTON. CA 68202 <br />` FEF AMOUNT DVE AMOUNT REMtTTEO SH RECEIVED BY GATE PEf1Mrl-NO. <br /> 4 INFO <br /> •EH I"fxEY.I Ins) /! F � �` � � ^ �-/;• v � A�� . <br /> EH 7426 <br />