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11 j <br /> *• I APPI,I CATI ON FOR PERI[I T <br /> SAN JOAQUIN COUNTYPUHLIC HEALTH SERVICES i <br /> :I ENVIRONMENTAL' HEALTH DIVISION <br /> :; II 445 N SAN JOAQUIW"'PHONE (209)468-3420 <br /> �h P O BOX 2009, STOCKTON, CA 95201 " <br /> PERMIT EXPIRES- 1^YEAH�iFROM DATE ISSUED <br /> (Complete in Triplicate) <br /> H <br /> Application is hereby made.to San Joaquin County for a permit to construct and/or install the vork herein described. Thisl <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. I !! <br /> II '! �� Il ,� II 1 <br /> Job Address 3Z t © iCity�"+DCG�#-nN Lot Size/Acreage <br /> VvtevYDvt USA 1 "C"t G. Address':�110C-mnv e, uu R--t4,-G4' Phone <br /> Owner's Name _._ II <br /> w � <br /> Contractor !1 Address 1-tt cir License No. 7 103VPhone 570`(af--G� <br /> TYPE OF WELL/PUMP: 11 AW WELL ❑ ' WELL REPLACEMENT 11 DESTRUCTION ❑ Out of Service Well ❑a! <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR p ,,.OTHERC INonitoring Well ❑ <br /> ..I .I ;.-� 5'o <br /> DISTANCE TO NEAREST: SEPTIC,TANK-> It,o SEWER.LINES >t oo DISPOSAL FLD>f� PROP. LINE i <br /> FOUNDATION AGAICULTURE WELL 716 <br /> .�.Q._ OTHER WELL!t_!I- _ PITS/SUMPS ,T <br /> INTENDED USE TYPE OF WELL PROBLEM AR ONSTRUCTION SPECIFICATIONS <br /> C7 Industrial ❑ Open Bottom ❑ M a Dia)of Well Excavation Dia. of Well Casing <br /> C1 Domestic/ Cl Gravel Pack Tracy Type of Casing_ Specifications <br /> I'1 Public Cl Other]' Cl Delta Depth'of Grout Seal "7Q/ !! Type of Grout <br /> I I Irrigation pprorr. Depth I I Eastern Surface Soul Installed by. K U i rylat it e <br /> Repair Work Done Type of Pump H.P.I` 'l State Work Dane_. <br /> Well best n O Well Diameter Sealing Material JE Depth <br /> Depth Piller Materiel i'Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION 111No septic system parmill rc Sawa► is <br /> available wit 081.1 ,. <br /> Installation will serve: Residence Commercial____ Others <br /> Number of living units: Number of bedrooms <br /> Character of soil to a1l !# <br /> depth of 3 feet: Wader table depth <br /> ` SEPTIC TANK ❑ TVpo/Mfn !' Capacity No.'ICompartmenta <br /> PKG. TREATMENT PLT Method of Disposal <br /> Distance to nearest: Well Foundarion Property line <br /> LEACHING LINE Cl No. flr,Length o1 lines I; Ij. 1' Total length/size <br /> I '$ <br /> FILTER BED ❑ Distance to un aUon Property Line ; <br /> Y 1 <br /> SEEPAGE PITS 1 1 Depth:j Size !' Iy Y Number ' w <br /> SUMPS Ll Distance to nau@st: We ' roperty Lin@ <br /> 1 hereby certify that I have prepared this application and that the work will ba done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County �1 Ip. 11 is <br /> Home owner or licensed agent's stiignature certifies the following: "I certify that in the performance of the work Ifor which this permit is,issued, I shall not <br /> employ any person in such manner as to become subject to workm in'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 /> The applica tt for all required ' tionif. a-covaree side. ' <br /> = Signed Title: Date: <br /> V - : <br /> FOR DEPARTMENT USE ONLY , �06 <br /> Application Accepted by I E, Date �F Area <br /> Ph or Grout Inspection by Date �'L ' Fin <br /> al spection by Date <br /> Additional Comments: W1 <br /> s=/I <br /> Applicant - Return all copies to: Xaa Joaquin County Fublicr'Health Services <br /> Environmental Health Permit/Services <br /> il13� 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201INA <br /> FEE AMOUNT DUE AMOUNT REMITTED CK!9!1... RECEIVED BY <br /> INFO CASH' DATE PERM17'N0. <br /> ♦ fM 11 IRM I/lr 51 j I�. TJZ ( ,Zo! (3 x 1��tJ�F5 <br /> I <br />