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 /> R FRQX PATE ISSUED <br /> (Complete in Triplicate) <br /> Application I hereby trade to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address "-` City Lot Size/Acreage <br /> Owner's Neme�.� Address Phone <br /> Contract` �kense No r ' Phone r f <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT !1 DESTRUCTION ❑ Out of Service well 0 <br /> PUMP INSTALLATION ID SYSTEM REPAIR LAY OTHER O 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 O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> omestic/Private Cf Gravel Pack 0 Tracy Type of Casing Specifications <br /> Z) Public C1 Other © Delta Depth of Grout Seal Type of Grout <br /> Ml Irrigation Approx. Depth 0 Eastern Surface Seal installed by <br /> Repair Worst Done FJ-- Type of Pump H,P. 3 State Work Done ' Y'�� ��✓✓"fes' � <br /> Well Destruction O Well Diameter Sealing Material i Depth <br /> Depth Filler Material 4 Depth N <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L] REPAIR/ADDITION 0 DESTRUCTION G (No septic system permitted if public sewer is <br /> available within 200 fast.) <br /> Installation will serve: Residence^ Commercial—. Other <br /> Number of living units: Number of bedrooms <br /> Character of toil to a depth of 3 feet: __ Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments C <br /> PKG. TREATMENT PLT. D Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. 8 Length of lines Total length/size <br /> FILTER BED [_I Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I l Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <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 kensed 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 m II f all requirscl�inspections. Complete drawing on r verse side, <br /> Signed Title: r Date: s —i <br /> -FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Q Area �`� G <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 O B 09, STOCKTON, CA 95201 <br /> IEEE AMOUNT DUE AMOUNT REMITTED CK REECEE.IIVV�}ED BY } DATE PER 17 N0. <br /> . EH 1].2{IltEV.I)hS) YY(�J q� 0-0 0��/ V ! l� QZ QZ 2So <br /> EH 1{•2e <br />