Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 96201 <br /> (209) 468-3447 <br /> PERMIT M1995 I R <br /> (Complete in Triplicate) <br /> Application Is hereby made to San Joaquin County for s permit to construct and/or Install the vork herein described. This <br /> ma <br /> application Is de in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address S t aD �{ City 12 Lot Size/Acreage <br /> Ow er'a Nams r ss Phone — <br /> o r o rase Wense No. Phone <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACE ENT ❑ DESTRUCTION ❑ Out of Service Well C1 <br /> PUMP INSTALLATIOI SYSTEM REPAIR D OTHER ❑ Monitoring well CZ <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 CONSfi,RUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. a} Well Excavation Dia. of Well Casing <br /> estic/private ❑ Gravel Pack 11 Tracy Type of Casing Specifications <br /> M Public Cl Other ❑ pelta Depth of Grout Seal Type of Grout <br /> 0 Irrigation __.Approx. Depth ❑ e tern Surfice Seal Installed by <br /> Repair Work-Done-­O—Type-of-Pum H, - =�- -- x State.Work Don <br /> Wail Destruction O Well Diameter Sealing Material i Depth <br /> Depth \Filler Material i Depth <br /> I / � <br /> _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION-M- OESfi-RUCTION Ci INo septic system permitted it public sewer is <br /> a available within 200 feet.) <br /> — Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character o soil to a depth of 3 feet: ' Water table depth O <br /> SEPTIC TANK. ❑ Type/MfgCapacity ' No. Compartments <br /> PKG. TREATMENT PLT. ❑ ` Method o'1 Disposal <br /> Distance to nearest: Well Foundation i Property Line ! <br /> LEACHING LINE ❑ No. 8 Length'of lines a Total lerpgth/ai:e - <br /> FILTER BED ' n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number i- 1 <br /> SUMPS LI Distance to nearest: Well Foundation Property Line r 1 <br /> DISPOSAL PONDS 13 �. <br /> I hereby certify that I have prepared this application and that.the work will-b_a_do_ne in_accordance with San Joaquin county Ordinances, state laws, and O F <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 al'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 Californla." ll <br /> The applies m LCall to fired ' spections. Complete drawing on raver fide. <br /> Signed Title: Date: <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted byDate - l Asea <br /> Pit or Grout Inspection by Date Final Inspection by`1 Date.4 <br /> Additional Comments: _ <br /> Applicant - Return e.11 copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1 <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOR 2009, STOCKTON. CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> P� IL?/— <br /> NEH 13- IREV.tiiM$i �f /t y / <br /> EH.1-26 // <br />