Laserfiche WebLink
APPLICATION - <br /> r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> I I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete ;in .Triplicate) <br /> ,a <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:649 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> I Job Address' c��G/[l City <br /> 1 Cit Lot Size/Acreage ��g <br /> 1 J �u - - - - Phone V <br /> i Owner's Na���e Address <br /> r7 <br /> Contractor N a Address e4?kA& License No. � Phone <br />{ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well <br /> 'i 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 /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of'Well Excavation Dia. of Well Casing u'x <br /> El Domestic lPrivate ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> (1 Public Cl Other (I Delta Depth of Grout Seal Type of Grout �? <br /> I I Irrigation i; �..Approx. Depth ( I Eastern Surface Seal Installed by C <br /> 1 Repair WordDone U Type of Pump H,.P. State Work-,Done_ <br /> r Well Destruction ❑ Well'Diameter ' Seaing'Msterial-&`Depth` <br /> Dep a Filler Material & Depth .W <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> 1 available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other <br /> Number ofiliving units: Number of bedrooms , <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑✓`.Type/Mfo _ Capacity No. Cbmpartments <br /> PKG. TREATMENT PLT. 0-1� Method of Disposal <br /> L Distance to nearest: Well <br /> 1 Foundation Property Line <br /> ifi � <br /> LEACHING LINE ❑ No. & Length of-lines Total length/size l <br /> FILTER BE6i ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I' Depth Size Number <br /> SUMPS ;� Ll Distance to nearest:-' . Well Foundation Property Line <br /> DISPOSAL-PONDS- ❑ - <br /> I hereby certify that I have prepared this application and that the work will be done in accordance w.ith:,San Joaquin county ordinances, state laws, and <br /> rules and rag'ulations 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 applicanvffmi IC req 1 ns. Complete drawing on reveLa�siddee.. p ! Q <br /> Signed X (I itle: e3%�-r`� "s e Date: <br /> �„...� <br /> F R"DEPARTMENT USE ONLY <br /> Application Accepted by _ � - Date�� �� < Z. Area <br /> Pit or Grout Inspection by ~�``! Date Final Inspection by Date ¢, <br /> Additional Co <br /> 14 , <br /> mems: <br /> Applicant - Return all copies to: San JoQuin County Public Health Services <br /> i1 Environmental Health Permit/Services <br /> 3 ti 445VN�San Joaquln� P-0 Boz 2609,, Stkn, CA 95201 <br /> FEE s + <br /> INFO AMOUNT DUE AMOUNT REMITTED . CASH RECEIVED BY GATE PERMIT'NO. <br /> -`, �� <br /> f -',EH13IREV.Iixsl', f1, i94 �s��{ Q„ -e___. '_ �. , 7 �C.� Zp�V7 <br />