Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION NaV3 <br /> P 0 BOX 2009, STOCKTON, CA 95201 PO Bv ,LkU <br /> (209) 468--M4-73qP-C [� i <br /> p u IT EXPIRES 1 YEAR FROM DATE ISSUED <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 coupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services/. <br /> Job Address <br /> ,� l" )J IE City ^- Lot Size/Acreage <br /> - <br /> Owner's Name -� Address Phone <br /> Contractor N LAI\ ddress � � C (-`—" � license No. !'��♦[Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 71 DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <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 /> (l Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> L Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> MPublic Cl Other ❑ Delta Depth of Grout Seat Type of Grout <br /> G Irrioation Approx. Depth ❑ Eastern Surface Soul Installed by <br /> Repair Work Done U Type of Pump H.P, State Work Done <br /> Well Destruction O Well Diameter Sealing Material i Depth <br /> Depth Filler Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: R once 'Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity— No. Compartments <br /> PKG. TREATMENT PLT. Q Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. b Length of lines Total length/size <br /> FILTER BED C-) 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 /> 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 San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "1 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 following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tiorf-Ie ooff California." <br /> The, <br /> ap nust call itt elLLt2liS±iro rlsp!cti n late drawing overse sid / <br /> Signs Title: 4 Dater <br /> '' OR DEPARTMENT USE ONLY q <br /> Application Accepted by _�-- .� , , -- Date 2_ 1 `� Area <br /> Pit or Grout Inspection by Date Final Inspection by Date Z 6 <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 O BOX 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO rt`��r''� CASH /� ��� \ '(lam �j lql— <br /> EH 13.24(REV.rinse ""_ � �l! L 1� lI � <br /> EH A-25 l cn� <br />