Laserfiche WebLink
APPLICATION FOR PERMIT <br /> s <br /> I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1 <br /> t / _ ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 i <br /> (209) 468-9447 .3`l- <br /> I <br /> R <br /> (Complete 1Triplicate) <br /> tall <br /> work <br /> in <br /> Application is madebin�c a lto San iance withuin SanCounty Joaquinor a county Ordinancermit to nstruct No. 549gandole628and theeRules andeRegulationsdof Sans <br /> application is made � <br /> Joaquin County Public h Services. <br /> 7k, b��-6�, City Lot Size/Acreage <br /> Job Address <br /> Phone <br /> ` fJ Address <br /> Is �J �...,..,.._ . <br />` Contractor LL Address <br /> L cense No. Phone <br /> NEW WELL ❑ WELL REPLACEMENT [7 DESTRUCTION ❑ out of Service Well Cl <br /> TYPE OF WELL/PUMP. OTHER ❑ Monitoring 4te11 �� <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 <br /> .�.---- <br /> """ SEWER-CINES _____`"" """"-DISPOSAL LLD: PROP''L M <br /> DISTAIVCE`TO'NEAREST:'SEPTkC'TANK- AGRICULTURE WELL OTHER WELL — PITS/SUMPS <br /> FOUNDATION _ � <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> C] Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation <br /> tType of Casing Specifications <br /> U Domestic/Private ❑ Gravel Peck ❑ Tracy Depth of Grout Seal <br /> M Type of Grout <br /> I <br /> Public ' ❑ Delta i-1 Other irrigation �..Appross. Depth r!]-Eastern Surface 5i�'InSta}led by <br /> H P State Work Done _ <br /> Repair Work Dons [3 Type of Pump Sealing Material i Depth <br /> Wall Destruction © Welt Diameter Filler Materiel h Depth. _ <br /> Depth rmitied if public sewer is <br /> IE tic system pe <br /> TYPE OF SEPTIC WORK: NEW WSTALtATION 1 REPAIRlADOfTION L'1 DESTRUCTION available within 200 feet.) <br /> Installation will serve: Rest oncemrnarciel Other. — <br /> Number of living unity: Number of bedrooms r <br /> Water Labia depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK O Type/Mfg Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. G1 <br /> Distance to nearest: Well Foundation Property Line <br /> Total length/size ; <br /> LEACHING LINE ❑ No. 8 Length of lines Property Line <br /> FILTER BED El Distance to nearest: Well . � Foundation r <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Lina <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 taws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the fallowing: "I certify that in the performance of the work for which this permit is issued, I shell not <br /> employ any Doreen in such manner as to 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 of California." ti, <br /> i The applica �,_ yllwired pec on Com a drawing on r rse <br /> Signe Title: <br /> Dole: �J -----t/- <br /> 1 TMENT USE ONLY <br /> _._ Date r }\res -- <br /> Application Accepted by <br /> Data <br /> ty <br /> r <br /> Pit or Grout inspection by Date Final inspection by <br /> s <br /> Additional Comments: <br /> Applicant - Retura all copies to: EBLIC HEALTH SERVICES <br /> NNVVIRONMENTALJOAQUIN OHEALTH UNTY ODIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> �- Cx RECEIVED By DATE PERMIT'NO. <br /> FEE <br /> INFO AMOUNT DUE AMOUNT HEMrTTEO CASH <br /> ,74D 0 ---1 00 <br /> . 1iH 17-7 {PEV.1�M61 <br /> EH u•ir <br />