Laserfiche WebLink
APPLICATION FOR PERMIT <br /> " P SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �s <br /> ENVIRONXENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 tj U (�L p: <br /> (209) 468-3447 c� �•���5 } <br /> Y <br /> (Complete in Triplicate) <br /> Application is hereby Mde•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 1862 and the Rules Lad Regulations of San <br /> Joaquin County Public Health Services. <br /> City Lot size/Acreage <br /> Job Address .--�--— <br /> Owner's Name �-IAI Address <br /> Phone <br /> '• <br /> Contractor L[�6m Address <br /> e f8 € License No. �y-��3'�d Phone `39 7 <br /> TYPE Of WELL/PUMP: _ NEW WELL ❑ WELL RE=PLACEMENT ❑ DESTRUCTION ❑ Out of Service Weil Cl <br /> Monitoring Well 0 <br /> PUMP INSTALLATIO ❑ SYSTEM REPAIR ❑ <br /> OTHER ❑ <br /> pDISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES OTHER WELL PITS/SUMPS _ <br /> FOUNDATION AGRICULTURE W <br /> INTENDED USE TYPE OF WELL yPROBL AREA T NSTRUCTION sPECIFECTT10NS pia. of Well Casing <br /> f1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specilications <br /> U Domestic/Private ❑ Gravel Pack ❑ Trac Type of Casing <br /> Ito Depth of Grout Seal Typo of Grout <br /> Z) Public (-1 011ier © • <br /> 6Irrigation Approx, Depth Eastern urface Seal Installed by <br /> Repair Work Dons L] Type of Pump H.P. State Work Done <br /> Sealing Ma jai i Depth <br /> Well Destruction ❑ WellDiameter Filler Materi & Depth <br /> Depth F0 <br /> TYPE OF SEPTIC WORK: NEW INSTAL ON l REPAIR/ADDITION 0 DESTRUCTION sNailseptic <br /> able thin system <br /> permitted <br /> if public sewer is <br /> Installation will serve: Residence Commercial— Other <br /> f -Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:. " Water table depth <br /> SEPTIC TANK ❑ Typo/Mfg Capacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT• Q <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED L! Distance to nearest: _Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth }Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line ' <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 laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies ilia fol "I certify that in the performance of the work for which this permit is issued, I shall not <br /> pensation laws of California," Contractor's hiring or sub-contracting signature <br /> employ any person in such"manner as to become subject to workman's corn <br /> cenifies the following: "I certify that in the performance of the work_for rwhich this permit is issued, I shall employ persons subject to workman's compensa- <br /> tlon laws of California." <br /> The applicant must cal for all r uired ins coons, Cam te drawing on reverse side, <br /> oil <br /> Signed <br /> Title: — Date: <br /> FOR DEPARTMENT USE ONLY / <br /> Area <br /> Application Accepted by _ <br /> Pit or Grout Inspection by Date._. ' AY Final Inspection by Det <br /> Additional Comments: <br /> Applicant Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES w <br /> ENVIRONMENTAL HEALTH-DIVISION PERMIT/SERVICES elk <br /> ENVIRONMENTAL <br /> 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 95201 t`yV <br /> EE RECEIVED BY DATEPERMET NO:SF <br /> NFO AMOrLU�{NT DUE AM4VN7 Rt MITT EO CASH R QIq t '�ytEN 13.24 IRev.I/a 6ijv l i � ``� 6 417" l R� { ,Z <br /> t:hr;i•20 <br /> 1 <br />