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- --ss <br /> APPLICATION FOR PERMIT <br /> rS <br /> SAN .IOAQUIN COUNTY PUBLIC HEALTH SERVICES nn <br /> ENVIRONMENTAL HEALTH DIVISION �[� t`t�' <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O 13O% 2009, STOCKTON, CA 95201 <br /> EXP RES 1 YEAR FRQM DA <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. ) <br /> X•Job Address <br /> -KI L" City �� '✓ Lot Size/Acreage <br /> Phone <br /> Owner's Nam L� f b E:T� Address a- 3 , <br /> y D Lo ti E Address License No. Phone j <br /> `Contractor DESTRUCTION Ll Out of Service Well ❑ p t <br /> WELL REPLACEMENT ❑ toring Well T' <br /> TYPE OF WELL/PUMP:. NEW WELL ❑ SYSTEM REPAIR Cl OTHER ❑ C.] 4 <br /> PUMP INSTALLATION ❑ <br /> SEWER LINES DISPOSAL FLO. OP. LINE <br /> p1STANCE TO NE EPTIC TANK AGRICULTURE WELL OTHE - PITS/SUMPS <br /> FOUND <br /> SPECIFICATIONS <br /> INTENDED USE TYPE:OF WELL P REA CONST Dia. of Well Casing <br /> C] Industrial ❑ Open Bottom ❑ Manteca of Well Excavation <br /> racy Type of Specifications-,- <br /> [I Domestic/Private ❑ Gravel Pack Type of Grout <br /> I'1 Public I-1 Ot n Delta Depth of Grout.Seal <br /> I I Irrigation T.Approx.`Depth I I Eastern Surface Seal Installed by <br /> H.P. State Work Done <br /> Repair.W one L7 Type of Pump Sealing Material Depth <br /> Well Destruction ❑ Well Diameter Filler Material & Depth <br /> Depth <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION l 1 REPAIRIADDITION 1 I. DESTRUCTION a�vailssp"c ithin 20system 0 feetifed if public sewer is <br /> Installation will serve: Residence Commercial^ Other <br /> Number of living units: Number of bedrooms Water table depth / <br /> Character of soil to a depth of 3 feet: Capacit No. Compartments <br /> SEPTIC TANK. ❑ Type/Mfg y <br /> Method of Disposal <br /> PKG, TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> tal length/size "{ <br /> LEACHING LINE ❑ No. & Length of lines To - <br /> FILTER BED CI Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth Size Number (� <br /> SUMPS LI Distance to nearest: Well Foundation— — Property Line {+ <br /> i <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 ordinances, state laws, an <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "l 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 sub-contracting 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 /> iThe applicant must call for all required inspections. Complete drawing on reverse side. <br /> ?(Signed X Title: . _ <br /> - pats: 3 0 I <br /> OR DEPARTMENT USE ONLY r <br /> Date <br /> Area <br /> ` <br /> Application Accepted b.y ) <br /> Date -- Final Inspection by Date <br /> Pit or Grout Inspection by _ <br /> o Additional Comments:. <br /> Applicant - Return all copies to: Ban Services, EEnvi otmmentaliHealth <br /> HealthPermit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 / <br /> CK RECEIVED BY DATE PERMIT ND. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO (`]� <br /> EH l3.24 MEV.rr's1 4:' r <br /> f EN ta•xe <br />