Laserfiche WebLink
` p -- 12 <br /> APPLICATIOH' 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 /> t7 <br /> PERMIT M I RE S I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Applicatio is hereby made,to Sam Joaquin County for a permit to construct and/or install the work herein described. This <br /> applicsti ie made in corgaiance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaqui, unty Public health Services. <br /> Job Address ® City Lot Size/Acreage <br /> Owner's Name C Address Phone <br /> Contractor ! Address 33 License N Phontl%� <br /> PE OF WELL/PUMP:,,____ NEW WELL ❑ WEIrL REPLACEMENT n, DESTRUCTION Cl Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well O <br /> DISTANCE TO NEAREST:SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Peck ❑ Tracy Type of Casing_ Specifications LA <br /> l'1 Public fl Other n Delta Depth of Grout Seal Type of Grout <br /> I <br /> i Irrigation Approx. Depth l I Eastern Surface Seal Installed by F <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> i . <br /> WeH Destruction ❑ Wel! Diameter Sealing Material iDepth <br /> Depth Tiller Hater <br /> r' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ I;I -0ESTRUCTtON I INS pt system permitted if public sewer isl <br /> f availa within 200 feet.) <br /> r I <br /> Installation will serve: Residence Commercial Othe <br /> Number of living units: Number of bedropms <br /> Character of soli to a depth of 3 feet: # _ Water table depth <br /> e <br /> SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments^ ° <br /> PKG. TREATMENT PLT.❑ _Method of Disposal ` <br /> " Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE CI No. & Length of linesTotal length/size <br /> j <br /> FILTER BED ❑ Distance to nearest: Wall Foundation Property Line <br /> SEEPAGE PITS I ) Depth Size Number A / <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby comity that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and ,r <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 /> 1 empioy any person in such manner as to become subject to workman's compensation taws of California."Contractor's hiring or sub-contracting signature <br /> r certifies the following: I unity that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compenss- <br /> ` tion laws of California," <br /> X <br /> he app)' st call r r ad inspections. Complete drawing on reverse side.igned Title: Data: ) ! <br /> FOR DEPARTMENT'USE ONLY <br /> Application Accepted by wwn epft EM: b-N . __ Date — Area 192 <br /> F Pit or Grout Inspection by Date Final lnipection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public.Realth Services \[ �„ <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> CK 8 R INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N/0�. <br /> . Ex 12124(Nov.I/RS) - © .© CGS. ` / 1 -���9 e� 173- <br /> 9H t1-26 <br />