Laserfiche WebLink
APPLICATION FAR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES I YEM FROM DATE SII <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 Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address City Lot Size/Acreage <br /> Owner's Name <br /> AM&WAddress Phone <br /> "=e2 <br /> Contractor LI�G. Address License No. p/ Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑' WELL REPLACEMENT ❑ --DESTRUCTION-o--out-of-service-wel3-1=1 -�-I <br /> PUMP INSTALLATION)'JffJ5P-/,&E-SY T �EPAIR 11 OTHER El Monitoring Well C]DISTA CEJO NEAREST: SEPTIC TANK SEWER LIPf _' , ` DISPOSAL''FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL a OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> i <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing r <br /> [1 Domestic!Private <br /> I-] ravel Peck L3 Tracy Type of Casing T T Specifications <br /> 1'1 Public rl ther K _ F1 Delta Depth of Grout Seal" Type of Grout <br /> g 517#1 . , <br /> Irrigation T,:}] Approk�Cfapth I I Ea torn � Surface Saul lnstailad by � ss ' <br /> Repair Work Done U Type of Pump H.P. 'f,State.Work Done e� <br /> Well Destruction 13 Well Diameter _ _I� Sealing Material A Depths ew /7 0 <br /> Depth l biller Material A Depth- 4 i7 ff <br /> a <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l I lNo septic system permitted if public sewer is <br /> >� _available within 200 feet.i <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: -- =Water table depth i <br /> SEPTIC TANK ❑ Type/Mfg Capacity " 'No.,Compartments <br /> PKG. TREATMENT PLT.❑ .L�Method of Disposal <br /> Distance to nearest: Well Foundation—,,PropertyLina <br /> LEACHING LINE 0 No. li Length of lines Total-length/site' <br /> FILTER BED_ - 0-Distsnca to nearest.--- Well ---Foundation-- Pibperty-Line" <br /> SEEPAGE PITS l 1 Depth -Sirs - Number <br /> SUMPS LI Distance to nearest:` ,Wili_4­ Foundation Property'Eine <br /> DISPOSAL PONDS ❑ <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 licen�ed agent'i tlipnaturs certifies the following; "I certify that in the performance at the work for which this permit is issued, 1 shah 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 /> eertifies 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 s tions. Complete drawing on reverse aide. <br /> Signed X Title: Date: <br /> �...-� FOR DEPARTMENT USE O.r <br /> Application Accepted by Date 2 � Area <br /> Pit or Grout Inspection by Data nal Inspection by Data <br /> Additional Comments: !' 4,t,1OCL <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N Sen Joaquin, P O Box 2009, Stkn, CA 95201 <br /> 'aa <br /> FEE AMOUNT DUE AMOUNT REMITTED K I RECEIVED BY DATE PERMIT'NO.,:. <br /> INFO y� 1� CASH r p <br /> • EH M24(REV.IiPt5) �F_ J 3 ,��• ��f .� Zt� ��P� <br /> EH 14.26 <br />