Laserfiche WebLink
APPLICATION �.. <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of Sen <br /> Joaquin County Public Hes�jt�_Services. <br /> Job Address) rJ9A1Z!S� d _ Cityi { Lot Size/Acreage <br /> L e--ss Phone <br /> Owner's Name f � }} II �j�' <br /> Contfactor�S.Z._�G�Address �Q LA.). C ense No.� aq Phone <br /> ­TYPE OF WELL/PUMP: - - NEW WELL 0 ... WELL REPLACEMENT-❑..,._-_. . . DESTRUCTION_Cj Wi oP 3ervice_Neii—D. <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <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 /> n Industrial -❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing <br /> [-I Domestic/Private ❑ Gravel Pack C1 Tracy Type of Casing_- Specifications <br /> VI Public Cl Other n Delta Depth of Grout Seal Type of Grout <br /> t I Irrigation Approx. Depth t I Eastern Surface Seal Installed by !!! <br /> Repair Work Done L] Type of Pump H,P, State Work Done <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth _. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I TRUCTION I k Mo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— <br /> Number <br /> esidence _Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: ! Is Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments -<� <br /> PKG.TREATMENT PLT. ❑ I Method of Disposal I <br /> Distance to nearest: Well Fdundation Property Line <br /> LEACHING LINE C4­10. & Length of Innes Total length/size.. <br /> FILTER BED C) Distance to nearest: Well Foundation f Properly One <br /> t <br /> SEEPAGE PITS I I Depth F _SireNumber <br /> SUMPS U_�i-tance to near : T Well, Foundation Property Line <br /> - <br /> DISPOSAL PONDS D <br /> I hereby certify that I have prepared this application_and-that-the_work will-.be.done_in.accordan.:e,with San Joaquin county ordinances, state laws, and f <br /> rules and regulations of the San Joaquin County S <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person 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 person`s subject to workman's compensa- <br /> tie ws of CaiifornI t <br /> The appil t II to aN r quire s ti ns C�Ietodrawing on arse sid i r <br /> Sign Title: -�7'1 Date: <br /> FOR DEPARTMENT USE ONLY fff <br /> Application Accepted by _ eL A Date Area `S <br /> Pit or Grout Inspection by Date Final Inspection by Datd <br /> Additional Comments: <br /> Applicant - Return all copies to; San Joaquin County Public Health Services t <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED I CK RECEIVED BY GATE PERMIT'NO. <br /> INFO ) i ` CASH _ <br /> . EH 13-24 IREV.Iinai [/ !j -� `�I• J�V�� �I��� �l 17� <br /> EH 14.26 VVVIII II <br />