Laserfiche WebLink
x 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 /> YEA R <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 1662 and the Rules and Regulations of Ban ; <br /> Joaquin County Public Health Services. ! /� <br /> Let Size/Acreage <br /> 1(Job Address r7 r <br /> /�C�l'4"u�s 14't�� /r9•� Address (P k%aay �1 Is~a �C� Ph <br /> / I <br /> Owner's Name . .., <br /> License No <br /> Contractor <br /> Address . Phone <br /> Well <br /> Of <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION ❑ Out MonStariCe well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER)5S C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> PtTSlSUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> El Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> U Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing <br /> .. fa Oih�r © Delta Depth of Grout Seal Type of Grout <br /> M Public <br /> 0 Irrigation _Approrr, Depth D Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H,P. State Work Done , -,- <br /> Sealing Material & Depth 0 <br /> Well Destruction ❑ Well Diameter Filler Materiel & Depth <br /> Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION Ll REPAIR/ADDITION 0 DESTRUCTION ZI allo septic systelable shin m POfeetr'led if public sewer is r ,� <br /> G <br /> Installation will serve: Residence— Commercial-,._ Other <br /> -- <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Property Line <br /> Distance to nearest. Well Foundation P Y <br /> LEACHING LINE Ll No. & length of lines Total length/size <br /> I4 FILTER BED Cl Distance to nearest: Well Foundation Property Line <br /> I` <br /> r SEEPAGE PITS 11 Depth Size Number (� <br /> r SUMPS Ll Distance to nearest: Well Foundation Property Line , <br /> F DISPOSAL PONDS ❑ <br /> I ISPOS certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> herebyrules 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 /> eerlifies 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 must call for all required inspecti� Complete drawing on reverse side. <br /> V Signed Title: ., <br /> Date: <br /> F DEPARTMENT USE ONLY [� <br /> Application Accopted by4Date res �J <br /> Pit or Grout Inspection by Date Final Inspection by Dots <br /> Additional Comments: <br /> Applicant Return all cogias to: EN <br /> ENVIRONMENTAL HEALTH DIVISION RduIN OUNTY UBLIC LPERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON. CA 98201 <br /> FEE MOUNT DUE A:MO;UNT REMITTED CK RECEIVE D BY DATE PERMIT N0, <br /> INFO CASH <br /> . EN,s.z„RE,,.,,�s, St �o <br /> EN".Ie <br />