Laserfiche WebLink
i <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, .STOCXTON, CA 95201 <br /> PERMIT EXPIRES 1 YM FROM DATE S <br /> (Complete in Triplicate) <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 compliance with Baa Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. i <br /> !� City N Lot Sime/Acreage <br /> Job Address / <br /> Address <br /> Owner's NaPhone <br /> ,a( Address &- License No �—Phone <br /> Contractor ' <br /> TYPE OF WELL/PUMP: NEW WELT. ❑ WELL REPLACEMENT i'7 DESTRUCTION ❑ Out of Service well Q i <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> OTHER ❑ Monitoring well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ; <br /> INTENDEd USE TYPE OF WELL PROBLEM AREA frCONSTRUCTION SRECIFICATEONS i i <br /> M Industrial ElOpen Bottom [IManteca Dia. of:Well Excavation" K Dia. of Well Casing <br /> ' -` 'Type of Specifications. — <br /> Cm <br /> l Doestic/Privets ❑ Gravel Pack ❑ Tracy <br /> 1'1 Public t 1-1 Other n Delta 'Depth al ,rout Sea{. Type of Grout. -- *\ <br /> c. 1 �- [ <br /> I 1 Irrigation I _.._ Approx. Depth t I Eastern Surface Seul Installed by i <br /> Repair Work Done L] Typo 01 Pump ` <br /> li.P. State Work Done <br /> sealing'ffaterial..i Depth--- <br /> Well Destruction ❑ Well Diameter f of e <br /> Depth '-,..hiller Material i Depth i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION 1 I DESTRUCTION I I-1,N6 septic system permitted it public sewer is <br /> f ^-� <br /> available within 20Q feet.i ? <br /> Installation will serve: Residence k1-1 Commercial Other <br /> Number of 1vinq units. Number of bedrooms %f <br /> �q <br /> Character of'sop to a depth of 3 feet:. <br /> `'� "� !_Water table depth <br /> SEPTIC TANK. ❑ TV <br /> o.^l %` - Cspacity No. Compartmentsj <br /> PKG. TREATMENT PLT. ❑ 4 x Method of Disposal <br /> •� <br /> q€ Distance to nearest: Welll�,,Founvdstiori Ptoperty,;line <br /> LEACHING LINE No-A Length of lines --,Total lengthlsizti <br /> FILTER BED [Igistance to,nearest; Well •Foundations R fp f 77 Property Lina -#Ua <br /> SEEPAGE PITS *Y4 Do; Si:e µ^ r^ sty Line <br /> 1 SUMPS 7 LI Dfistance to nearest: Well otindsnon � Pro <br /> DISPOSAL PONDS ❑ i_' .. . ."' .". .'... "w,o.: a.{ i ` i i <br /> I hereby certify that I have prepared this application and.fhat the work will be done in accordance with Sari Joaquin county ordinances, state lbws, and <br /> rules and regulations of the Sen Joaquin County <br /> Home owner or licensed agent's iignature oertifies.the following:"I certify that in the performance d}the'work for which this permit is issued, 1;shall not <br /> employ sny person in such manner as to becorne`subject to workman's Cslifornis."?Contrsctor' <br /> s compensation lawts hiring or sub-contracting'signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is isiued, I skall employ persons subject to workman's compensa <br /> tion laws of California." v_ <br /> k <br /> F The applicant mm <br /> ust call for requir ins ons. Coplete{drawing on reversi side. <br /> r <br /> s Signed %_ 1 Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> 1 Date Ars, - :211 <br /> Application Accepted by �t . <br /> € t <br /> Ph or Grout inspection by 1 Date Final Inspection by Date _ <br /> k � t <br /> Additional Comments: <br /> Applicarit - Return all copies to: San Joaquin County Public Health Services <br /> 4 Environmental Health Permit/Services <br /> k / 445 N Sad Joaquin, P O Boz 2009, Stkn, CA 95201 j <br /> R II <br /> iINFE AMOUNT DUE- AMOUNT REMITTED CK RECEIVtED BY DATE PERMIT•NO. <br /> 4r <br /> • <br /> 13 24 itE , I EM V ! I / aJ S- <br /> EH ta•Ie , <br />