Laserfiche WebLink
` APPLICATION FOR PERMIT <br /> I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICTS <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 408-3447S" PAQX <br /> y. <br /> ' 4 <br /> (Calnplete is Triplicate) <br /> �, [`'�' <br /> pPlication Is hereby made to Ban Joaquin County for a permit to construct and/or ineta]l the work herein des d ;This <br /> application Is roads in coal3ance xith'San Joaquin County Ordinance No. 5bg and 1862 and the Rules and Regulation^�atfan <br /> Joaquin County Public Health Services. <br /> Job Addressr <br /> T City t Size/Acreage <br /> Owner's Nam* Address <br /> t Phone <br /> Contra or A / <br /> TYPE OF WELL/PUMP: NEW WELL ❑ sense No. Phone /� f✓ <br /> WELL REPLACE NT n DESTRUCTION ❑ Out of S <br /> PUMP INSTALLATION ❑ SYSTEM REPAI ervice Well Cl <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ Monitoring Well <br /> FOUNDATION <br /> _� SEWER LINES ^ DISPOSAL FLO. PROP, LINE J <br /> AGRICULTURE _,^____WELL <br /> OTHER WELL PITSISUMPS <br /> INTENDED USE T_ <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> m0 Industrial ❑•Open Bottom ❑ Manteca Dia, of Well Excavation <br /> astic/Private ❑ Gravel Pack ❑ Trac Ria. of Well Casing <br /> M Public y Type of Casing Specifications <br /> ' f'1 Other p Delta Depth of Grout Seal <br /> Cl lrrigation :Approx. Depth [] Type of Grout <br /> Repair Work Done 0 TYPe of Pum t►at rn H P Surface Seal Installed by <br /> Well Destruction 0 WOW Diameter Sealing Material & Depth State Work Do J , <br /> Depth Filler Material i Depth 4 (l <br /> TYPE OF SEPTIC WORK: MEW INSTALLATION LJ REPAIR/ADDITION 1:1 DESTRUCTION Ct lNo septic system permitted it public sewer is <br />,,,,Installation will serve:,Y Residence Commercial. Other available within 200 feet,} <br /> Number of living units: Number of bedrooms r -- <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK 0 Type/Mfg Water table depth f _ <br /> PKG. TREATMENT PLT. 0 Capacity' No. Compartments <br /> Distance to nearest: Wail Method of Disposal ' a <br /> Foundation _. Property Line <br /> LEACHING LINE L� No. & Length of lines <br /> FILTER BED 171 Distance to nearest: Well _ Foundation Property Total length/size <br /> y Line <br /> SEEPAGE PITS 11 Depth <br /> SUMPS Sire Number <br /> CI Distance to nearest: Well Foundation <br /> DISPOSAL PONDS C1 # ---- Property Lina <br /> I hereby certify that f have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, <br /> Joaquin County <br /> es, state laws, and <br /> rules and regulations of the San <br /> employ any person in.such manner as to become subject 10 workman's compensation laws of California." Contractor's hiring or subcontracting signature <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 /> certifies the following: "I certify that in the performance Of the work for which this permit is issued, I shall employ, <br /> tion laws of California." persona subject to workman's com <br /> The applica 7tust till or 11 required inspections,-Complete drawing on r eras tide. penes <br /> Sig ad � <br /> Till <br /> _.,. date: <br /> F R DWrARTMENT USE ONLY <br /> Application Accepted by <br /> Dat / "216/� I <br /> Date 2 / tea �^ <br /> Pit or Grout Inspection by'-- <br /> Date Final Inspection by <br /> n � <br /> Additional-Carrtments:���---� Dat <br /> --Applicant Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ` <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES i <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, 3TOCKTON, CA 95201 <br /> — - FEE AMOVNT gt1E AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE <br /> PERMl7'NO. <br /> EH tJ-24IREV, <br /> EH 14.2e <br />