Laserfiche WebLink
APPLICATION FOR PERMIT <br /> NO V <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICEq:,,�,e ,:' ' <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 APR 15 1 <br /> 1:��\ ) _ -- I <br /> PENIT EXPIRES 1 YEAR FROM DATE Isaul&NVIROIF'\iVA! WAL <br /> i <br /> ­ Th <br /> (Complete in Triplicate) P fT__RM"I .1�io►-� `VIIGES <br /> i _k <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. 549 and 18 2 and the Rules and Regulations of San <br /> Joaquin County Public Health Services., <br /> Job Address Cit Lot Size/Acreage <br /> Phone <br /> Owner's Name <br /> CX� License NO. if?14� Phone <br /> c 0, A <br /> 0 ', s' <br /> ice Well 0 <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACE ENT DESTRUCTION 0 out of Sery <br /> OTHER ❑0 Monitoring Well <br /> PUMP INSTALLATIO SYSTEM REPAIR 0 <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD._ PROP. LINE <br /> FOUNDATION — AGRICULTURE WELL _ OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> [.l Industrial 0 Open Bottom 0 Manteca Dia,- of Well Excavation <br /> ,�estic/Private 0 Gravel Pack 0 Tracy Specifications <br /> Depth <br /> ype of CasingM Public (I Other 0 Delta of Grout Seal Type of Grout <br /> Cl Irrigation Approx. Depth 4 Etstern Surface Seal Installed by <br /> Repair Work Done [J Type of Pump H.P. lZa State Work Don <br /> Well Destruction 0 Well Diameter sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION 0 (No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commvrctvf-_----ether <br /> Number of living units: — Number of bedrooms <br /> Character of *oil to a depth of 3 feet: Water table depth <br /> SERTlili TANK 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation— Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED ( 11 Distance to nearest; Well Foundation — Property Line <br /> Goo� <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation— 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 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 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 Californla." <br /> The applicant ust <br /> �r all required.inspections. Complete drawing on rev v s' <br /> Date: <br /> Sig s Title: <br /> DEPARTMENT USE ONLY..,. —4/ <br /> Application Accepted by eg�i� Date 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 RECEIVED BY DATE PERMIT NO. <br /> INFO CASjrI <br /> APAP <br /> EH 13-24 IREV.I/A 5)IV hl-(n3-71 <br /> EH A.26 <br />