Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> RACEI V" D <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 JUN 2 3 1992 <br /> (209) 468-3447 OV1RONMENTAL HEALTH <br /> "MIT ESPIRES I YEAR PROM DATE ISSUED PERMIT/SERVICCS <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 cosipliance with Sari Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services.7 <br /> Job Address < City~ °Lot Site/Acreage <br /> Owner's Name1r_ - Address Phone <br /> Contrac Addresp License �� Phon l <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION Ll Out of Service Well CD <br /> PUMP INSTALLATION ❑ _ 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 /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> M Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> omesticIPrivate 0 Gravel Pack C7 Tracy Type of Casing Specifications <br /> ID Public ill Other 0 Delta Depth of Grout Seal Type of Grout i <br /> G tmoation .Approx, Depth ❑ Eastern I Surface Seal Installed by <br /> Repair Work Done P__1`Type of Pump , H.P. 'State Work Done <br /> Well Destruction 0 Well Diameter Sealing Material & Depth I <br /> Depth Filler Material & Depth y <br /> TYPE OF SEPTIC WORK: NEW"INSTALLATION.0 REPAIR/ADDITION Ll DESTRUCTION CI (No septic system permitted it public sewer is <br /> available within 200 feet.l <br /> Installation will serve: Residence— Commercial — Other IN <br /> i <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth Q <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. C) Method of Disposal (� <br /> Distance to nearest: Well Foundation Property Line �l <br /> LEACHING LINE C1 No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> s = <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation m r - Property Line <br /> DISPOSAL PONDS 0 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and <br /> rules and regulations of the San Joaquin County 1 <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 applicant mu all requiredjnspections. Complete drawing on r verse side: <br /> i ` 1 t <br /> Signed 7L � .�!_._.._._ Title: � Date: <br /> J <br /> R EPAiiTMENT USE ONLY / <br /> Application Accepted by Date r rest <br /> Pit or Grout inspection by Date Pinel Inspection b —rte 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 O BOX 2009, STOCKTON, CA 95201 <br /> FEEINTO} AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY ZPATE PERMIT NO. y� <br /> EH 13.241FIEV.s/it 51 <br /> Elf,z.ae Y y CJ <br /> I <br />