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APPLICATION FOR PERMIT <br /> i <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> f r <br /> P O-BOX 2009, STOCKTON, CA 95201 <br /> PXRMIT EXPIRES 1 YEAR FRAM 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 1$62 and the Rules and Regulations of San <br /> Joaquin County PublicHealthSe vic //'�� <br /> Job Address / g ti r City " Lot Size/Acreage lJ f <br /> Owner's Name M f` Address ` +" Phone 9 1�9_3� <br /> Contractor ass S "a License No. Phone 9111 <br /> TYPE Of WELL/PUMP: NEW WELL ❑ W LL REPLACEMENT ❑ DESTRUCTION D Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LIN 5 �i]lSPO�Ifi("FLO. �4 •OROP. LINE <br /> FOUNDATION AGRICULTU E L' OTHER WELL ,PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM ARE ONSTRUCTION SPECIFICATIONS + f <br /> ❑ Industrial ❑ Open Bottom ❑ Mantec ia. of Well Excavation Dia. of Well Casing <br /> 1 <br /> Cil Domestic/Private L-1 Gravel Pack ❑ T y ype of Casin <br /> g Specifications <br /> VI Public CI Other Delta epth of Grout Seal ' Type of Grout <br /> I I Irrigation �.Approx. De 11 Easternurface Seal Installed by ~w[ '' J <br /> Repair Work Dane 0 Type of Pump H.P,. `f�•. - f. State Work Done_ <br />[ Well Destruction ❑ Well Diameter Sealing Naterial &,.Depth= <br /> a Depth Fillerterial 6 ptti I f �' Ary <br /> F M. - <br /> `°" TYPE OF,5EPTIC WORK: NEW INSTALLAI.LQWI I REPAIR/ADDITIgN�I DESTRUCTION.i.I {No septic system permitted, public sewer is <br /> u ✓ -1 X 1 ­4,;.'�4I available within 200 eet.) $ c - <br /> Installation will serve: ResidenceAl <br /> �f Commercial ther%' <br /> Number of living units: Number of bedrooms <br /> :.� _ <br /> Character of soll to a depth of 3 feet:- <br /> C T Water`tabl`e depth <br /> SEPTI <br /> ..y <br /> TANK. ❑ Type/Mfg� �" Capacity. No. Compartments <br /> PKG, TREATMENT PLT.❑ ! t Method of Disposal <br /> Distance t nearest: Well 4 - Foundation --� Property Line <br /> LEACHING LINE Cl No. & Length of lines if T­-4length%size <br /> FILTER BED ❑ Distance to nearest: Well Foun tion ..Property Line <br /> Line ' <br /> F <br /> SEEPAGE-PITS 1 11 Depth I Siie mb r I <br /> SUMPS*% 1 LI Distance to neare Wellundation�Property Line f: <br /> DISPOSAL PONDS Cl JL t - { <br /> I hereby certify that I have prepared this application and that[he work will be done in accordance with,San Joaquin county ordinances, stafe`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 taws 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 applican ust c r all req'red insPections. Complete drawing on reverse side, I <br /> Signed X lonTitle: `�V <br /> Date: _ _ <br /> OR PARTMENT USE ONLY, ^ t ' <br /> Application Accepted by n kin. Date Area <br /> Pit or Grout Inspection by YDatei Final Inspection by ' Date t <br /> - IAdditional Comments: <br /> i <br /> Applicant- Return all copies to: i-San Joaquin County Public Health r <br /> IServices, Environmental Health Permit/Services <br /> 1601 E. Razelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE r <br /> O AMOUNT Dt1E I AMOUNT REMITTED CK if <br /> CASH RECEIVED BY DATE PERMIT NO. <br /> + EH 13-24 IREV.i i A sl [ !� p <br /> EH F4.26 4 lPp. <br />