Laserfiche WebLink
APPLICAV�M& FOR PERMIT <br /> k <br /> j S � <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � <br /> I� ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 i <br /> (Complete in Triplicate) <br /> Application is hereby made to San, <br /> County for a permit to construct and/or install the work herein described. This <br /> application is made in eomplianct with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> �Z�.-� �g�5' On I A City�dr7 ��� Lot Size/Acreage s <br /> f�Job Address —� <br /> �\ �.. 1' c.c��l lryy"T� ,C D d" i-t Phone 3 $Z 2 J <br /> Qwner'sName N aQRC Address ��S �' <br /> I� cc>r9�,c.�? . Phone 333 8z 3 <br /> ontractor <br /> Address C ' �Z License No. <br /> TYPE OF WELLIPUM?'' VIEW WELL © WELL REPLACEMENT F] DESTRUCTION Cl Out of Service Well Ci <br /> PUMP INSTALLATION X SYSTEM REPAIR 0 OTHER ❑ <br /> Monitoring Well [.I ' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f_l Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic I Private 0 Gravel Pack 0 Tracy Type of Casing Specifications. - <br /> Type of Grout <br /> Q Public l71 Other ❑ Delta Depth of Grout Seal <br /> Gl l(rigation —Approx. Depth ❑ Eastern Surface Said installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done �. <br /> Well Destruction © Well Diameter Sealing Material i Depth <br /> Depth IM Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEWINSTALLATION J REPAIR/AODITION M DESTRUCTION F-I 1No septic system permitted it public sewer is / <br /> available within 200 feet.) <br />` installation will serve: Residence Commercial _.,. Other <br /> Number of living units: Number of bedrooms yj <br /> Character of soR to a depth of 3 feel: Water table depth <br /> No. Compartments ' <br /> SEPTIC TANK ❑ Type/Mfg Capacity 4 I <br /> P.KG. TREATMENT PLT. O i Method of Disposal <br /> I Distance to nearest: Well Foundation Property Line •-w"' <br /> LEACHING LINE Cf No. & Length of lines � Total length/si3e � *" <br /> FILTER BED' n 'bistance,to nearest:` Well Foundation Property Lina <br /> I <br /> SEEPAGE PITS i I Depth IM Si:e Number ! <br /> SUMPS Ll Distanc:`to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ yb �.. t <br /> I hereby certify that I have ppared this application and that the work will be done in accordance with San Joaquin county ordinances, state la <br /> rews, and <br /> rules and regulations of the San Joaquin County , / <br /> Home owner or licensed agent's signature certifies the following, "t certify that in the performance of the work for which this permit is issued, 1 snail not <br /> employ any person in such manner as jo 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 work for which this permit'is issued, i shall employ persons subject to workman's compensa• <br /> tion laws of California,' <br /> The applicant must call for all required <br /> inspections, Complete drawing on reverse side <br /> -- <br /> Signed �' Tide' S,a - Date: <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by Date ,—.3 1 Area <br /> Pit or Grout Inspection by IE.. Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> II 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON. CA 85201 <br /> FEE OVNT DUE AMOUNT REMITTED CASH CK 9 RECVVED BY DATE PERINIT N0. <br /> INFO <br /> . EH 13-24(REV.t/A51 +y�', -�� <br /> EH ' <br /> ,�•Ie 1� �+ u <br />