Laserfiche WebLink
APP LLAT I ON <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> Pe , PERMIT MIRES 1 YEAR FROM DATE ISSUED <br /> p (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 SerIvice6. <br /> t— f, <br /> Job Address � � ,�",n�,QP„!•,_ r/—' City '� Lot Size/Acreage <br /> Owner's Name _P _ 2_��� f Address S� -e Phone <br /> Contractor Addressar/tjp�cense No. Phone 519�2 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER p Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private "❑ Gravel Pack - 0 Tracy Type of Casing_ Specifications <br /> F) Public 1-1-Other Cl Delta Depth of Grout Sea! TYPa of Grout <br /> I i Irrigation Approx Depth”JI Eastern `--Surface"Seal Installed by <br /> Repair Work pone 116 Type of Pump H.P. —�? ,- State Work,Dtirie <br /> Well Destruction ❑ Well Diametei -Material JG Depth <br /> Depth Filler Material 6 Depth 4` <br /> TYPE OF SEPTIC WORKP NEW INSTALLATION I 1 REPAIR/ADDITI.ON 1 1 DESTRUCTIONA I (No septic system permitted if public sewer is <br /> r '�` available within 200 feet.) <br /> Installation will serve; Residence Commercial„ Other <br /> Number of living units: Number of bedrooms r' -- - '•.r <br /> Character of soil to a depth of 3 fee;: Watei table depth 1 <br /> SEPTIC TANK ❑ T e/Mf " <br /> trP 9 Capacity No. Compartments i <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No.-A Length of lines } Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS LI Distance toii nearest;.J1 Well Foundation Property Line ' <br /> DISPOSAL PONDS ❑ f <br /> I hereby certify that I have prepared this'ap'plication..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 I ',I" <br /> Home owner or licensed agent's signature ceiti(es 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 shell employ persons subject to /Man's.,ompen6a <br /> tion laws of Califor <br /> The applic us all for all required tins'"ons.'ons. Complete drawing on reverse side. <br /> Signed Title: Date: <br /> c FOR DEPARTMENT USE ONLY <br /> Application Accepted by _ Date F d <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection by V e, Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> A 445 N San Joaquin, P 0 Box 2009, Stkn; CA 95201 <br /> FEE INFO AMOUNT DUE ; AMOUNT REMITTED CK 9 <br /> CASH RECEIVED BY DATE PERMIT 0. <br /> . EH73-24 IREV.1)N51 � <br /> EH 14•28 '?+` <br />