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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 0 BOX 2009, STOCKTON, CA 95201 <br /> PEUIT EXPIRES 1 YEAR FROM 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 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address City Lot Size/Acreage .. <br /> Val <br /> Owner's Name 43i. FAdi4ress * "— f }� Phone - C <br /> ^Contractors r <br /> Address_ JO License Idol a `._ Phone <br /> TYPE OF WELL/PUMP: NM WELL ❑ WELL REPLACEMENT E DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTE EPAIR 0 OTHER C) Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPftC TANK _-- `""SEWEiR-tIN DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTU . WELL OTHER WELL PITS/SUMPS <br /> r' INTENDED USE TYPE OF WEAer <br /> AREA ONSTRUGTION SPECIFICATIONS <br /> C] Industrial ❑ Open Bottoma ia, of Well Excavation Dia. of Well Casing <br /> CJ Domestic/Private LJ Gravel Pack �pe of Casing Specifications <br /> f'I Public Cl Other �pth of Grout Seal Type of Grout <br /> I I Ifrigation .Approx. DIrface Seal Installed by <br /> Repair Work Done 0 Type of-•Pump- Wp. - State Work DoneWell Destruction ❑ Wel! DiameterSealing terial & Depth <br /> Depth,KFiller Material Depth r <br /> \ I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I J REPAIg/ADDITION I T DESTRUCTION l I (No septic system permitted it publR'c sewer is <br /> lam/ available within 200 feet. \. <br /> Installation will serve:'s Residence— `Commercial_ Other <br /> Number of living units: Numberiof bedrd6ms <br /> Character of soil to a depth-of 3 feet t} ti Water'sable depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity O No. Compartments <br /> PKG. TREATMENT PIT:❑ Method of Disposal <br /> : Distance to nearest: WellFound, ion Property Line <br /> LEACHING LINE . Cl No. & Length of lines Tegal.length/size <br /> Jt J <br /> FILTER BED LJ Distance t6 nearest: Well Foundation Propert Line (� <br /> SEEPAGE PITS I�l Depth; Size mbar 1 <br /> SUMPS , L`I Distance to nearest: Well 'oundation Property Line-!-2f <br /> �DISPOSALPOND54- ❑�� � e <br /> �I hereby certify thif I have prepared this-applicati6n and that the work will be done in accordance with San Joaquin county ordinances, state 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 laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the wokfor which this'permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." V�, I <br /> The applican utt call f I requir inspections. Complete drawing on reverse'slde, <br /> Signed F Title:e: � Date: <br /> r f F IDEPAHTMENT USE ONLY J <br /> Application Accepted by Date Area 2' 11 " <br /> Pit or Grout lnspecti n,by' ' Data Final Inspection by ' �D'ate <br /> Additional Comments: '+ <br /> Applicant - Return all copies t�: an Joaquin County Public Health <br /> Services,_Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED C K# RECEIVED BY DATE PIFERMIT'NO. <br /> c EH 13-A{REV.i i n ss 1� •� y, (�� F <br /> EH sa:2a•�_ 1 11 4 q 1 [[[ JI <br /> - l <br />