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1 <br /> fl' APPLICATION FOR PERMIT <br /> I' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> . } ENVIRONMENTAL HEALTH DIVISION. - <br /> '��/ P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 {V O Q <br /> R <br /> (Complete in Triplicate) •lt� <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. Thij�L <br /> application 1e made in coma liance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban <br /> Joaquin County Public Health services/. <br /> Job Address City City Lot Size/Acreage <br /> Owner's Name>45— 4 . Sh- Address Phone <br /> Contractor Address CLn6!?�nse No. Phone <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER p Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack 0 Tracy Typo of Casing Specifications <br /> M Public Cl Other f ❑ Delta Depth of Grout Seal Type Of Grout <br /> CI Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done_ <br /> Well Destruction O Well Diameter Sealing Material i Depth <br /> i <br /> Depth Filler Material ti Depth i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION n- REPAIR/ADDITION 0 DESTRUCTION p ,c system permitted if public sewer is <br /> 1 available within 200 feet.) <br /> Installation will serve: R dente L�mmercial Other <br /> Number of living units: Number of bedrooms <br /> Character of Boil to a depth of 3 feel: Water table depth <br /> SEPTIC TANK Type/Mfg -. Capacity No.,Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE CI No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Welt Foundation Property Line <br /> m y 1 <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Lina <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, 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 /> any person in such manner as to become subject to v0Wr ani compenaaffon laws of}Cald;r' iia." Contractor's hiring or sub-contracting signature <br /> enifias following: "I that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> t)on laws of o Is," <br /> Th pphcant mu II or all r 0.n C e drawing o o rse side. <br /> Signs Tits <br /> f Date , <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by � - �f�~T Date Area 1 <br /> Pit or Grout Inspection by Date Final Inspection by Datd v <br /> I <br /> Additional Comments, <br /> Applicant Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 945 N SAN JOAQUIN, P 0 BOK 2009, STOCKTON, CA 98201 <br /> FEE AMOUNT DUE OUN7 fiEMtTTED CK RECEIVED BY DATE PERMIT'Np. <br /> EMF CASH <br /> EH 13-24 <br /> tNEV.,,KSI o16- 1- !?D 90 2L <br /> h <br />