Laserfiche WebLink
lam . F <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES N DW � <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201. -jl�,:7A <br /> (209) 468-3447 <br /> PERMIT �7tDTRTiS 1 YEAR ItROd DAT�_.I$�11� <br /> (Complete in 'Triplicate) Q) _ <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in coupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> �ob Address <br /> 3 City—9&61U6,9-/Lot Size/Acreage <br /> 1wner's Name Address _� 7 d __ Phone <br /> t�ontraclor Address License No. Phone i <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Out of Service Well 1 <br /> SYSTEM REPAIR ❑ OTHER 0 C <br /> Monitoring Well C7 <br /> PUMP INSTALLATION ❑ " <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION_ AGRICULTURE,WE.L'L OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f7 Industrial ❑ Open Bottom ❑ Manteca Dia, af'Well Excavation Dia. of Well Casing <br /> U Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications <br /> C1 Public r "i" I') Other ❑ Delta Depth of Grout Seal Type of Grout_ -- <br /> CI Irrigation Approx, Depth fl Eastern "Surface Seal Installed by <br /> Repair Work Done v Type of Pump H-P. State Work Done_ <br /> Weil Dsftruction,.-f w_ ❑ Weil Diameter Sealing:Naterial i Depth <br /> Depth =-,y, � Fillerfldaterial i Depth <br /> 3 TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0. DESTRUCTION (No septic system permitted if public sewer is " <br /> available within 200 feet.l <br /> Installation will serve; Residence— Commercial Other <br /> Number of livitiy units: Number of bedrdomis <br /> Character of wil to a depth of 3 feet: Water table depth r <br /> SEPTIC TANK ;❑ Type/Mtg - Capacity_tNo. Compartments <br /> _, i ! <br /> PKG. TREATMENT PLT:GI Method of Disposal, . _ " <br /> Distance to nearest: ; Weil Foundation Property Line <br />{ LEACHING LINE .❑ No. $ Total length/size <br /> of lines -� -_-, 9 <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> kf � " <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well YFoundation Property Line <br /> DISPOSAL PONDS El <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 <br /> rules and reputations of the San Jobquih 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 cortnpenaation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, E shall employ persons subject to workman's compensa• <br /> tion laws of California," <br /> The applicant mut: ca fo all req d ins :tions. Complete drawing on re side. <br /> igned Tide: <br /> Date: <br /> "{ Y` R D AATMXNT USE ONLY <br /> Application Accepted by Oats - Area <br /> t Pit or Grout Inspection by <br /> Data Final Inspection by Date <br /> Additional Comments: - <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95241 <br /> INFO AMOUNT RUE AMOUNT REMfTTED [A6t RECEIVED BY DATE PERMIT"NO. <br /> FEE <br /> . EH 13-74(REV.1{r151 7 c 0 c7 7 ( O 0 <br /> EH A-Ia <br />