Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRE Y FROM DATE ISSUED <br /> (Complete_ in Triplicate) <br /> Application is hereby mode to flan 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 186P,and the Rules and Regulativns of San <br /> Joe in County Public Health Services. I �L. <br /> Job Address 1 Q 1 1 City1(' Lot Size/Acreage <br /> P (q3 - a <br /> OYinw./�ne'r's Name _..._—� Address Phone j <br /> ConlTact� Adresv "LMcense No. �t3 honeJ �`� <br /> TYPE OF WELL/PUMP: NEW WELL IT WELL REPLACEMENT � DESTRUCTION ❑ Out of Service well 0 <br /> PUMP INSTALLATION C1 SYSTEM REPAIOTHER ❑ Monitoring Will ❑ <br /> R/ep <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES- DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> � F <br /> INTENDED USE TYPE OF WELL PROBLEM AREA' CONSTRUCTION SPECIFICATIONS <br /> El Industrial 0 Open Bottom ❑ Manteca. Die. of Well Excavation Dia. of Well Casing <br /> F) Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing` t Specifications <br /> `Il PPbk 1-1 Other fl Delta - -Depth of Grout,Seal Type of Grout <br /> 4ci lion _Approx. Depth I I Eastern Surface Soul Insfaiied by _ <br /> Repair Work Done U Type of Pump H.P. ' State Work <br /> —Sealing-Mat:erial,i-Depth-;.-- <br /> Depth <br /> th—_-�-_ <br /> Well Destruction D W@II Diameter � <br /> Depth - Tiller Material 16 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION+-I- REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available wilhin_200_feet.}. <br /> Installation will serve: Residence_ CommercialOther "' r , <br /> Number of living units: Number of bedrooms <br /> Character of soli to a depth of 3 feet: r <X� Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity �NofCompsrtrnants� "F ' <br /> PKG. TREATMENT PLT. © - Method of Disposal- <br /> Distance to nearest:` Well Foundation Property Line ' µ' <br /> LEACHING LINE ❑ No. S LengthJof linea t Total length/size <br /> FILTER BED 0 Distance to nearest. Well Foundation Property Lina' <br /> s I <br /> SEEPAGE PITS it Depth Size Number <br /> SUMPS Ll Distance to nearest:"` Well FoundationProperty Line <br /> DISPOSAL PONDS ❑ � <br /> I hereby certify that I have prepared this appiication and that the work will,be-done in accordance with San Joaquin county ordinances, slate laws, and <br /> rules and regulations of the San Joaquin County + ! 1 f F,` . � i, (". .A, <br /> Home owner or licensed agent's signature certifies the following: "I certify.that"rn'.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 o}California Yccrittector_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__shall employ persons subject to workmeh'.s compensa- <br /> tion laws of Calif Is r . <br /> The applicant ca T uir inspections. Complete drawing o rev side. <br /> Signed Title: Date: <br /> OR DEPARTMENT USE ONLY• r 'ti <br /> Application Accepted by ”`"""r! V179— �')17- <br /> Aregl <br /> Pit or Grout Inspection by Date Final Inspects n by Dat@ fr <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stka, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH' RECEIVED BY DATE PERMIT'NO. <br /> EEN 13.21(REV.I i K 5) L45,o o r �✓ Z a r V <br /> N t1.2a <br />