Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> l P O BO% 2009, STOCKTON., CA 95201. <br /> PERMIT ESPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San V oaquiu County for a permit to construct and/or install the work herein described. This <br /> application is made in cawliancei with San Joaquin County Ordinance No. 51+4 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Serv'cen.or <br /> ZJ <br /> cif Lot Size/Acreage <br /> Job Address I d <br /> �t//� Cf C1 I /Jl`1 � Phone 3 ` <br /> XO w n a r's N a m a �d J "' —.�Address <br /> P6ntractor <br /> Address license No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL 11WELL REPLACEMENT ❑ DESTRUCTION Ll out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 13 OTHER O Monitoring well L3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> `FOUNDATION' -'�--- "-AGRICULTURE-WELL OTHER WELL -PITS/SUMPS <br /> - <br /> l <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casing- - Specilications <br /> C-1 Domastit4private ❑ Gravel Pack 0 Tracy g- Type of Grout <br /> I'1 Public 1-1 Other I F1 Dslta•. +:..--.Depth of Grout-Seat <br /> I I Irrigation —.Approx. Depth I I Eastern Surface Seat Installed by <br /> r H.P. State Work Done <br /> Repair Work Done U Type a1 Pump Sealing Material i Depth � <br /> s WON Destruction ❑ Well Diameter <br /> Depth - Filler Material i Depth <br /> TYPE OF SEPTIC WORK.NEW INSTALLATION I I`- REPT AIR/ADDITION I I DESTRUCTION NailabPerwi hin system ranted it public sewer is <br /> Installation will serve: Residence Cammercisl Other <br /> Number of living units: Number of bedrooms - <br /> Character of sop to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. O Type/Miq Capacity t`No. Compartments ^� <br /> PKG. TREATMENT PLT.❑ Method of Disposal �J <br /> t - <br /> Distance to nearest: Well Foundation Property Line <br /> ' LEACHING LINE ❑ No. 6 Length of linea Total lengthlsi2e <br /> FILTER BED ❑ Distance to nearest; Well Foundation Property Line <br /> f <br /> SEEPAGE PITS 11 Depth }1 Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> f DISPOSAL PONDS ❑ 1 <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 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 hat 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 Californ ' .� <br /> nfThe applicant mu or requir in no. Complete drawing on reverse side. , <br /> jJ�S.p Title: Data: <br /> FOR DEPARTMENT USE ONLY q <br /> Applieat' Ace ted by <br /> Date Are •Z <br /> Pit or Grout In tion by Date Final Inspection by Dat <br /> Additionst Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> fEECKSAMOUNT DtIE AMOUNT REMITTED CASH RECEIVED BY TE PERMIT'N0 <br /> INFO 1 y <br /> E . EM 1124(REV.t/KSI c� <br /> EM 14•�e � <br />