Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PEUIT EXPIRES 1 YEAR PROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application Is hereby made tc 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 sad Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address City <br /> /� s® Lot Size/Acreage <br /> I <br /> Owner's Name ' `� Address Phone /� <br /> �`_Address icense No. Phone 7 <br /> • Contractor hy�..l..¢ I <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT O DESTRUCTION O Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> J <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> M Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public 1:1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> CJ Irrigation Approx. Depth D Eastern Surface Seal installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material Z Depth <br /> Depth Filler Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION PAIR/ADDITION 0 DESTRUCTION LI (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: es* encu LLommercial Other <br /> R <br /> Number of living units: Number of bedrooms2� <br /> Character of toil to a depth of 3 feet: C L Water table depth <br /> SEPTIC TANK ❑ Type/Mfg CapacityZ GO No. Compartments <br /> PKG. TREATMENT PLT. 0 / f Method of D*�pgsai <br /> Distance to nearest: Well "� Foundation Property Line�). <br /> LEACHING LINE 134--tT. & Length of lines —3, Total length/size f <br /> FILTER BED to Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 1'i'_Depth Size -3 Q�N fnber <br /> SUMPS LI Distance to nearest: Well _5V 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: "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 /> cpaifies 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 a t Ca'tornla.' <br /> The applica tt call fo all qui ins ct mplete drawing on(averse side <br /> 9 <br /> Si ns Title: 1L�. Date: r <br /> kKQR DEPARTMENT USE ONLY S <br /> Application Accepted by Data <br /> Pit or Grout Inspection by Date Final Inspection by Date Cv <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 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> . EH 13.24 IREV.i/n SI / j /f�7 <br /> EM.1.16 <br />