Laserfiche WebLink
• � APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE0,I4 <br /> CENVIRONMENTAL HEALTH DIVISION <br /> P O BOR 20099 STOCKTON, CA 95201 h E <br /> E I Vt U, <br /> (209) 468-3447 OCT 9 11°I <br /> pLUIT EX IRES 1 YEAR PROM DATE IssuftGiRaNft ENTAL HEATH <br /> (Complete in Triplicate) 111i i /;ER'd' S) <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 San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban <br /> Joaquin County Public Health <br /> �1gPervic <br /> Lot Site/Acreage <br /> 0b GWO" <br /> /f — <br /> re Phone <br /> wner' tli7�t .. <br /> rat or <br /> ass License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACE NT 71 <br /> DESTRUCTION O Out LI <br /> PUMP INSTALLATIONrte.��ktSYSTEM REPAIR ❑ OTHER O 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 /> Ll Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> mastic/Private O Gravel Pack O Tracy Type of Casing Specifications <br /> M Public 1:1 Other O Delta Depth of Grout Seal Type of Grout <br /> G Irrigation Approx, E stern rSurlace Seal Installed by <br /> Repair Work Done U Type of Pump:=;rll <br /> H.P. State Work Don <br /> Well Destruction O Well DiameterSealing Material i Depth <br /> DepthFiller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION CI (No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_. Commercial_ Other <br /> Number of living units: Number of bedrooms C <br /> Character of soil to a depth of 3 feet: Water table depth r <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 Cl No. i Length of lines Total length/size <br /> FILTER BED n 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 O <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: "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 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 /> tion laws of California." <br /> The ap lican µst c ll fo uirad Inspections. Complete drawing on rev ie side. <br /> fined Title Date: <br /> FOR DEPARTMENT USE ONLY ® �� <br /> Application Accepted by Data Area <br /> Pit or Grout Inspection by Date Final Inspection by DateIV <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 CASH RECEIVED BY DATE PERMIT N0. <br /> INFO <br /> EH 13.24 IREV. n 51v, 1 I '6—_X7 1Z <br /> EH-X <br />