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 /> otc>7►sTm try7RT� YEAR ®TE <br /> (Complete in Triplicate) <br /> vork <br /> in <br /> Application is hereby ma4e.toaSan rr�huBanCJoaquin Counr a ty Ordlnancermit to nNo .549 struct aandoi862 end ther inataii eRulee andeRegulstionadof Sana <br /> application is mads in compliance <br /> Joaquin County Public health Services. h a� <br /> fir` �' e `� City � Lot Size/Acreage cx <br /> Job Address3 6f <br /> ODC�`.et'- Phond�� f <br /> Owner's Name Address <br /> Address . <br /> y <br /> f - <br /> �� F License No. i$-3 Phone <br /> Contractorr h <br /> t TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT ❑ DESTRUCTION LI put of Service Well 0 <br /> OTHER C!,:) Monitoring Well <br /> PUMP INSTALLATION'$K SYSTEM REPAIR C7 <br /> r � •,,,� SEWER LINES ��� DISPOSAL FLD. PROP. LINE �' pf <br /> DISTANCE TO NEAREST 'SEPTIC TANK OTHER WELL -�f� PITS/SUMPS? <br /> FOUNDATION AGRICULTURE WELL <br /> r T r <br /> J. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION.,SPECIFtCATkONS <br /> Dia of Well Casing <br /> ( <br /> Open., n Bottom ❑ Manteca Dia. of <br /> El Industrial' WeIIExcavation <br /> s . �� Specifications <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type-of Casing / TYPe o} Grout <br /> € CI Public t-1 Other ❑ Delta Depth of Grout Seal �Q I �� <br /> CJ Irrigation r r tApprox. Depth Eastefn Surf lace Seal Installed <br /> Repair Work Done AL3 Type of Pump, H.P, State Work Done <br /> _ f. <br /> %} a Sealing Material & Depth <br /> Weft Destruction O Weil Diameter Filler Material & Depth <br /> Depth ' V <br /> TYPE OF SEPTIC WORK: NEW�INSTALLATION 0 REPAIRave�ADOtTION 1=I DESTRUCTION G septic system permitted if pubfic sewer is <br /> � . - available within 200 fee;.) <br /> f M <br /> Installation will serve: Residence — Commercial_ Other <br /> f lNumber of bedrooms <br /> Number of living units: a , <br /> Character of eoif to a depth of 3 feet: Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines <br /> �FILTEB " stance to nearest: Well Foundation Property Line € , <br /> f SEEPAGE PITS t I Depth Sire <br /> Number <br /> 4, <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> k DISPOSAL PONDS ❑ t Y� <br /> I hereby comity 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 Sen Joaquin County <br /> Home owner or licensed agent'&signature certifies the following: "I certify that in the performance of the work for which this permit is issued; I shall not. <br /> workman's compensation laws of California."employ any person in such manner as to become subject to Contiactof's hiring or sub-contracting signature- <br /> aenifies the following: "I certify that in the perfofmance of the work for which this permit is issued, I shall employ persons subject to workman's,compensa <br /> r tion laws of California." } <br /> The applicant must call for all required inspections. Complete drawing on reverse side. ' <br /> e <br /> Title* '�155—' "f =' Date: <br /> Sign <br /> L <br /> D MENT USE ONLY <br /> i Date Area t <br /> Application Accepted by 3 Q <br /> - rt <br /> Pit rout spection by ^� - Date -4 Final Inspection byKJ _ Data <br /> € <br /> Additional Comments: <br /> i <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 fi <br /> CK , <br /> " --'— -"FEE AMOUNT DUE AMOUNT REMITTED RECHVED BY GATE PERMIT N0. <br /> SH <br /> INFO (/JC.yjA� ' <br /> . EH13.24(REV,;t�5r 11�� `�• ' <br /> EH 14.26 <br />