Laserfiche WebLink
APPLICATION FOR PERMIT <br /> u <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> R=1T EXPIRES I YEAR VROM DATEj SM <br /> (Complete in Triplicate) <br /> Application Whereby made to San Joaquin County for a permit to construct and/or install the work herein' described. This <br /> 3 application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Servi <br /> Job Address City Lot Size/Acreage <br /> i Owner's Nam-Al ] Address Phone <br /> 4 Contractor JLC v ddress xicenseNo. 4-7•y-3zhtihne Q141 <br /> TYPE OF WELL/PUMP:.___.___NEW WELL O WELL REPLACEMEN C=1 DESTRUCTION ❑ Out of Service Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O K nitoring Well {7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1� <br /> ! n industrial ❑ Open Bottom D Manteca Dia. of Well Excavation Dia. of Weil1&sing <br /> S U Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications - <br /> f M Public (-I Other 0 Delta Depth of Grout Seal Type of Grout <br /> U Ir6oation —.Approx. Depth 0 Eastern Surface Seal Installed by M �J %; <br /> Repair Work Done U Type of Purnp H.P. State Work Done <br /> k Well Destruction ❑ Well Diameter Sealing Material i Depth C>P <br /> Fr pepth Filler btiteriali Depth '•�' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION DESTRUCTION CI (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial ther- <br /> �� Number of living units: _/_ Number of bedrooms _ ; ! <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC,TANK.' ❑ Type/Mfg Capacity No.-Zompartments <br /> PKG. TREATMENT PLT.❑ I <br /> .. _ Merhod of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> II t <br /> LEACHING LINE No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS $Depth Sire Number li <br /> SUMPS Ll Distance to nearest: Well Foundaiio 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 <br /> rules and regulations of the San Joaquin County <br /> ,Home owner or licensed agent's signature cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> F employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or suss-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 M orkman's compensa- <br /> tion laws of California." <br /> The nt N Cali for all ro e pact' s. Complete drawing on roversa side. <br /> Si ne <br /> g Title: Date: i <br /> _.SE-ONLY Q <br /> Application Accepted by Date _..i Area !� <br /> Pit or Grout Inspection by Date Final Inspection by A Dsta &[ U <br /> Additional Comments: <br /> f <br /> Applicant a Return all Copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES IY <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 i <br /> INFO AMOUNT DUE AMOUNT REMrTTED CASH I?ECEIVED BY GATE PERMITN0. <br /> Tr <br /> • EM ,t-24 InEV,i 1%i,) <br /> � Fla;s.2a l <br /> j <br />