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is <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> p O BOB 2009, STOCKTON, CA 95201 <br /> �• �ggM m EXPIRES 1 YEAR FROM DATE IM <br /> 1 (Complete. in Triplicate) Thi1 <br /> t Application is hereby made.to SanJoaquinCounty for a permit to construct and/or install the work herein RegulationsofSans <br /> application is Wade in cotapiiance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Aegis <br /> Joaquin County Public Health Servic e. <br /> dre3s <br /> 7n Got Site/Acreage <br /> Job Ad �. If <br /> Phone`G/ <br /> l 1 <br /> �'AddFess : .- <br /> -05 wner's Name <br /> 'Address �V 21�7 License No. Phone <br /> Confractot DESTRUCTION G Out of Service Well ❑ <br /> ELL REPLACEMENT'❑ Monitoring Well <br /> ~TYPE OF WELL/PUMP:' NEW ELL ❑ SYSAIR ❑ x OTHER ❑ ! <br /> PUMP INSTALLATION D. }` r <br /> SEWER LI S DISPOSAL FLD.) PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER WELV� PITS/SUMPS <br /> FOUNDATION AGRVCULT £ LL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA NSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> Q <br /> Industrial �❑ Open Bottom--�-❑ Manta_ca a. of Well Excavation "�� Specifications <br /> Cl Domestic/Private ❑ Grave! Pack] ❑Tracy T pe of Casing-- <br /> I'1 Pubiic C, Other I. 17 Delta <br /> 0 pth of Grout Sea! Type of Grout <br /> by <br /> Irrigatbn t _.ApproK.'Depth t I East S mace Sedi installed <br /> of Pum ! H.P. ' State Work Done_ 1 <br /> Repair Work Done )' U Type p t Sealing Material & Depth- <br /> well Destruction F ❑ Well Diameter <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: "NEW INSTALLATION I 1 REPAIR/ADDITION � DESThUCT10N l I available with 200'teeined if p rblic sews is + <br /> Installation will serve: 14V <br /> Residence— Commercial,_____ Other t <br /> f <br /> Number of living units: Number of bedroo <br /> (J L <br /> 1 W er t <br /> Character of soil to a depth of 3 feet: No, Compartments <br /> SEPTIC TANK. ❑ Type/Mfg ' Capacit ` <br /> Method of,Disposal <br /> PKG. TREATMENT PLT.Cl <br /> / Distance to ell Property Line <br /> nearest: Foundav n <br /> ' I <br /> I f — 1 <br /> Totai'length/size 1 �~ <br /> LEACHING LINE 0 No. & Length of lines property Line'-7 — <br /> FILTER BED ❑ Distance tri nearest: Well - i <br /> SEEPAGE PITS "I I- Del Sire umber <br /> SUMPS <br /> LI Distance to'ries est: .. . Well iAp�oundw on�� Property Line lj 1� <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this.application and that the work will 4e done.in accordance with San Joaquin county ordinances, state laws, ander` <br /> rules and regulations of the San Joaquin`,County <br /> '` Y I shall not <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of ttSe work for which this permit is issued, <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 partorrriance of_the work for which this permit is issued,I shall employ persons subject to workman's compel f <br /> tion laws of Califwnia." <br /> The applicants st call f required i spectiol Complete drawing on reverse side. <br /> r f Title: G9-1L.1JY\YI Date: J —� <br /> Signed X_ I <br /> OR,DEPARTMENT USE ONLY A- 4 <br /> r , <br /> s Area _ <br /> i Date I <br /> Application Accepted by 7 "1 <br /> i Oate y <br /> Pit or Grout Inspection by ,�/ ate FinaLln p on y <br /> Additional Oommema: 1 <br /> Applicant - Return al copies to``San-Joaquin County Public Health <br /> Services,-Environmental. Health Permit/Services r <br /> l 1601 E. Hazeiton-Ave` P 0 Box 2009, Stockton, CA, 95201 <br /> FEECK RECEIVED By DATE PERMIT NO. <br /> lNfOAMOUNT DUE AMOUNT REMITTED CAS <br /> EM 13.24 IREV.r i n 51 - <br /> EH:J.2e <br />