Laserfiche WebLink
APPLICATION FOR PERMIT &� <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION NOV 3 0 1990 <br /> P 0 BOX 2009, STOCKTON, CA 95201 ENVIROsNMIEN-11" aL HEALTH <br /> (209) 46$-3447 PIRMIT/SERVICES <br /> ARRI('tT ESDI ES 1 YEAR PROM 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 coapliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Jots Addrsas City Lot Size/Acreage <br /> Owner's Name ` rrasa -- Phone <br /> eG ntrbc or ss icInse No. Phone <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LI DESTRUCTION ❑ Out of Service well Ll . <br /> I <br /> PUMP INSTALLAT10>< SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> j DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> L 4 _ ,_ _ FOUNDATION AGRICULTURE WELL OTHER WELL _ PITS/SUMPS Y � <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> `In Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing <br /> ❑ Gravel Pack L7 Tracy Type of Casing Specifications <br /> /L Public 1.1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> Cl Ifrigation —Approx. Depth astern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump_ H.P. State Work Don <br /> Well Destruction 11 Well Diameter Sealing Material i Depth <br /> i Depth Filler Material i Depth <br /> TYPE OF . <br /> SEPTICWORK: NEW INSTALLATION❑ REPAIR IADDITION CI DESTRUCTION CI (No septic system permitted if public sewer is <br /> k available within 210 feetA <br /> Installation will serve: Residence— Commercial___. Other <br /> Number of living units: Number of bedrooms _v <br /> Character of soil to a depth of 3 feet:.—' Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg, Capacity No. Compartments <br /> I PKG. TREATMENT PLT.G7 Method of Disposal <br /> Distance to nearest:. Well�-`"-'-'"`Fiiundition?` Property Line <br /> ti <br /> LEACHING LINE L'1 No. 8 Length of lines Total jength/size <br /> } FILTER BED CI Distance to nearest: Well .Foundation' ` Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest:,. Well Foundation Property Line <br /> L __, DISPOSAL.PONOS__❑ <br /> I I hereby certify that I have prepared this application and that the work-will be done in accordance witW-San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County .t f <br /> Home owner or licensed agent's signature certifies,.the Iollowing: "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 /> aerlifies t the following: "I certify that in the pertofmnce of the work for which this permitjs issued, I shall employ persons subject to workman's compenss- <br /> tion laws of Californis." � <br /> The applica _ yet-csll_f aq, u'red_inspections.-Complete-drawing=on-revs <br /> r <br /> Sign l xitje: Date- <br /> - <br /> fi DEPARTMENT USE ONLY p.*. <br /> Application Accepted by <br /> Dale"L°7r / Area <br /> Pit or Grout Inspection by Date 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 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERM17'NO. <br /> INFO a I CASH <br /> EH 13.24 INEV.tiiwsi 7r b-- <br /> EH 74.2 <br />