Laserfiche WebLink
a 4 <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 O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to Saul Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in ceupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Servic4s. <br /> Job Address t JA30 CCA y t S1ze/Acreage <br /> r'a Nam, f� Address ° Phone O <br /> 1� <br /> MonOtoML_C Gt/ License No.4bg MPhone9 " 1 3 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT fl DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAiR� OTHER ❑ Monitoring Well n <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 /> 0 1 dustrial ❑ Open Bottom _ ❑ Manteca Die. of Well Excavation Dia. of Well Casing <br /> merstic/Private ❑ Gravel Pack ❑ Tracy Type of Casing- Specifications <br /> I'l Public [I Other n Delta Depth of Grout Seal Type of Grout / f] <br /> I I Irrigation —Approx. Dap I I .astern Surface Seal Installed by v <br /> Repair Work Done 0 Type of Pump H.P. 1 172- State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth iry <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION ( I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 fest.) <br /> Installation will some: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 fast: Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments (tJ7 <br /> PKG. TREATMENT PLT.0 Method of Disposal G <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 Sen 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 foMwing: "I unity,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 ap ' s ust call uired inspections. Complete drawing on rever side. <br /> Signed Title: Date: _ <br /> FOR EPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Ph or Grout Inspection ey Date Final Inspection by Date 7 92 <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services ,M[1 <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> INFO <br /> AMOUNT DUE L-AIMOUNT REMITTED CLASH RECEIVED BY -DfATEE APEERMIT'NO. <br /> - EH 43-24 IItEV. ist a) 1 It �r—0 i1 1 6'• t�� � l� � � 17~[Z I Z <br /> EH ts•2s <br />