Laserfiche WebLink
r <br />'IF <br /> 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 EgPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> r <br /> Application In hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application 1s made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> 1 Joaquin County Public Health Services. <br /> Job Address City Lot Size/Acreage <br /> Owner's Nam a Address �!st�. Phone <br /> Contractor Address Lidense Phone <br /> aw <br /> F TYPE OF WELL UM : NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ out of Service Well ❑ <br /> I PUMP INSTALLATION 13SYSTEM REPAIR OTHER CIMonitoring Well L] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> CI Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> kDomaslic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> 11 Public 1-11 Other F1 Delta Depth of Grout Seal Type of Grout <br /> e I I Irrigation _.Approx' De th 11 Eastern Surface Seal Installed by <br /> Repair Work Done $L Type of Pump H.P. , State Work Do a <br /> Well Destruction O Well Diameter Sealing Naterial i Depth <br /> Depth k ]tiller NaterisJ. i Depth +^' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve. Residence_ Commercial.. Other <br /> Number of living units: Number of bedrooms --•, <br /> Character of soil to a depth of 3 feed i a <br /> SEPTiCTANK. ❑ Type/MfgCapacity— <br /> PKG. <br /> apacity PKG. TREATMENT PLT.❑ <br /> Distance to nearest: well Foundation PropsplytLftie__.§__ <br /> 111HHR <br /> LEACHING LINE Cl No. 6 Length of lines Total len Oft <br /> FILTER BED ❑ Distance to nearest. Well' tit r Foundation �� PI L vieES <br /> l; rM I+r ,DIVISION <br /> SEEPAGE PITS 11 Depth Sue Number <br /> SUMPS ., - LI Distance to nearest: well Foundation Property Line <br /> F 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 laws, and <br /> rules and regulations of the San Joaquin County <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 persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant Will call for uire'd_insspecttions. Complete drawing on reverse si e. <br /> Signedpt <br /> Title: ] Dater - <br /> _ �OR -ONLY <br /> M <br /> Application Accepted by Date <br /> Pit or Grout Inspection by Date _ Final Inspection by _� Dated <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, Stkn, OA 95201 r <br /> I' IFEE NFO AM NT DUE AMOYNT REMITTED V CK R EIVED BY D TE PERMIT'NO. <br /> Ek 14-2a <br /> EH 13.241f1EV.151 <br /> k - <br />