Laserfiche WebLink
APPLICATION FOR PERMIT <br /> • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468--3447 <br /> P IT EXPIRES I r <br /> R <br /> (Complete in Triplicate) <br /> Application is hereby wade to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made c lance with San J urn County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County bl Hea Services <br /> XJob Address Cit Lot Size/Acreage { <br /> Owner's Name ss Phone <br /> �coMraclar Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Cl Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well o <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/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> M Public fa Other 0 Delta Depth of Grout Seal Type of Grout t <br /> G IrnUation .,,,..Approx, Depth ❑ Eastern Surface Saul Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material &-Depth-- <br /> Depth Filler Material i Depth <br /> TYPE OF .SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION Cl DESTRUCTION C1 (No-septic"system permitted if public sewer is <br /> '"available-.within 200 feet.l <br /> Installation will serve: Residence..` Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of loll to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. •• 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, ❑ -F M Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Wall Foundation Property Line <br /> SEEPAGE PITS 11 Depth., r Sire Number ' <br /> SUMPS -L1 Distance-to nearest, Welt- "Foundaiian {{' =-Property-Line - <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 i <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature Certifies the following: "I carlify that in the performance of the work for which this permit is issued, I shall not I <br /> employ any person in such mann to be ms subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following; "I certify hat in the rformancs 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 applica u call r d inspections. Complete drawing on reverse side. <br /> Signed <br /> Title: - - Data: r r <br /> �KCORNEPARTMENT USE ONLY �] <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by at �L <br /> M <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT FiEMITTEO CK RECEIVED BY D + <br /> INFO GASH ATE PERMIT�NO.^7 q <br /> t• EH A-I1 iRl`Y.I/R 51 '�� ��� l�L '� YA1 <br />