Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 1601 E HAZEENVIROL OFN AVE. , PHONE (20TAL HEALTH 9IONECEIIillil�� ' <br /> P O BOX 2009, SOCgTO )468-3420 R <br /> N, CA 9520] <br /> ,11:111 1� tillE%P RES I YEAR FROM DAT IDENVIRONM P <br /> (Complete in Triplicate + E'V4AL HEA <br /> Application 1s hereby made to San J } PERM, ' ��r� <br /> + application is made in compliance v1th Ba County for a permit to construct and/or install the work herein described. <br /> This <br /> Joaquin County Public Health Service San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Job Address <br /> ' Ity Lot 512e/Acreage <br /> Owner's Name <br /> Address <br /> , f Phone <br /> TYPE OF WELL/PUMP: ddress / <br /> NEW WELL ❑ Li ense N Phone <br /> PUMP INSTALLATION p WELL REPLC MEAT DESTRUCTION ❑ Out of Service Well L-)DISTANCE TO NEAREST: SYSTEM REPAI OTHER ❑ Monitoring Well <br /> SEPTIC TANK <br /> --�.w SEWER LINES ��� DISPOSAL FLD. C] I <br /> FOUNDATION PROP. LINE <br /> ----, AGRICULTURE WELL OTHER WELL <br /> INTENDED USE _ T1'PE'OF WELL PROBLEfVIAREA �-- PITS/SUMPS .� <br /> f 7 Industrial --��— CONSTRUCTION SPECIFICATIONS - <br /> © Open Bottom ❑ Manteca Dia. of Well Excavation <br /> omestic/Private <br /> ❑ Gravel Pack n Tracy T Dia. of Well Casing <br /> IPublic f 1 Other ype of Casing <br /> Delta Depth of Grout Seal Specifications <br /> I Irrigation Type of Grout <br /> XO <br /> -_.Approx, De th Eastern Surface Seal Installed r,yRepair Work DoneType of PumpWell Destruction H'P' State Work o <br /> Wel! Diameter Sealing Material & Depth (. <br /> Depth Filler Material & Depth "V <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I AEPAIR/ADDITION I I DESTRUCTION f I fNa septic system permittad;f public sewer i <br /> installation will serve: Residence available within 200 feat.► s <br /> Commercial Other "-^� ,_ <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK. ❑ Type/Mfg Water table depth <br /> PKG. TREATMENT PLT. C1 Capacity No Compartments <br /> t M Method of Disposal <br /> Distance to nearest: Well 4 T <br /> Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED ❑ Distance to nearest: Wsll�� -w. 'Total length/size <br /> Foundation Property Line <br /> SEEPAGE PITS f I Depth <br /> SUMPSSize ` Number <br /> LI Distance to nearest: Well ,�,� <br /> DISPOSAL PONDS ❑ Foundation Property Line <br /> I hereby certify that I have prepared this application and that rhe°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: ,hat ! <br /> employ any person in such manner as to become subject to woman s compe}nsat on lawsn the o of.Califorrniarmance of ��Contractwork foror s'h ringch s of sub-tont acttiAgl signature <br /> cnot <br /> ertifiescertifies the fallowing: "I certify that in the <br /> tion laws of California." performance of the work for which this permit is issued, I shall employ persons subject to workman's campensa- <br /> The applicant call for { ` <br /> 'ed-in Pe>ftions.-Complete-drawing-an rse - <br /> Signed <br /> T' <br /> Date: [ <br /> DEPARTMENT USE ONL <br /> Application Accepted by ..��p <br /> Data v Area <br /> Pit or Grout Inspection by <br /> ate^_-___`� Final Inspection by j t d <br /> Additional Comments: Date <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE <br /> IT <br /> PERM 'NO. <br /> EM 13.21 IREV.v x 51 ! , <br /> Eli§MIs <br /> z+o� <br />