Laserfiche WebLink
E <br /> APPLICATION FOR PERMIT NO NM <br /> t °SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION N10 AN< <br /> ;1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCSTON, CA 95201 ` <br /> PERMIT XP RES 1 YEAR R M DAT <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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> ' <br /> 3­2Ss � O �� CityE±6� Lot Size/Acreage <br /> Job Address _. , <br /> J{lam <br /> Owner's Name C1 Address Phone <br /> , � <br /> contractor [=lJ Address aS cense No. Phone 1 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well <br /> i, PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> OTHER O Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. UNE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL. _ PITS/SUMPS <br /> INTENDED USE TYPE Of WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> i <br /> Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> CI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 11 Public 1-1 Other I n Delta Depth of Grout Seal i Type of Grout n <br /> 1 1 irrigation —Approx. Depth I I Eastern Surface Seal Installed by U <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Depth e n <br /> Depth 2 Filler Material 6 Depth U <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION I 1 OESTRUCTI I septic system permitted if public sewer is <br /> i <br /> vailable within 200 feet.I <br /> Installation will serve: R idence�' --c-01r,ercial Other <br /> Number of living units: : Number of bedrooms <br /> tom_c Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ I Method of Disposal <br /> Distance to nearest: Well Foundation !Property Line <br /> 1 <br /> ' LEACHING LINE LI Nos& Length of fines 2� Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ "I <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 i <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, 1 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 ify that ir%the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> ti laws o ifornia." <br /> The applica must II for all re uir ins tions Co ate drawing o verse side. C� <br /> Signe ;Titter_ --Date:- <br /> RUOTMENT USE ONLY <br /> Application Accepted by Date 0 Are <br /> Pit or Grout Inspection by Date Final Inspection by Dete �� � <br /> Additional Comments: <br /> 'r <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> III I Services, Environmental Health Permit/Services " <br /> 1601 E. Raselton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> - 9 q S qJ 11 <br /> EN 111E <br /> i <br />