Laserfiche WebLink
r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 4 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> IP 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM MTE_ ISSPTD <br /> (Complete in Triplicate) <br /> k Application Is hereby made to Sa Josquin County for a permit to construct and/or install the work herein described. This <br /> application is made in coalpliance',with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Servic <br />€ Jab Address City <br /> t Size/Acreage <br /> OWLE <br /> Owner's Name t ' Phone <br /> Contractor fess A46telcense No Z;PHPhone <br /> TYPE OF W LL/ UMP: NEW WELL ❑ WELL REPLACEMENT np DESTRUCTION Li Out of Service Well Ll <br />' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L-1 Industrial !❑ Open Bottom C] Manteca Dia. of Well Excavation Dia. of Well Casing <br /> I.1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> 1'1 Public 1:1 Other Y fl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth I i Eastern Surface Seal Installed by <br /> Repair Work Done 0 Types of Pump H.P. State Work Done_ <br /> Well"Destruction ❑ Well Diameter` <br /> Depth Piller Nateri Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION M DESTRUCTION l I (No septic system permitted if public sewer is <br /> I available within 200 feetJ <br /> Installation will serve: Residence._,_.,1 Commercial_ Other <br /> Number of living units: Number of bedrooms T <br /> Character of soli to a depth of 3 feet: Water table depth <br /> .SEPTIC TANK. ❑.- Type/Mfg Capacity No. Compartments 0 <br /> PKG. TREATMENT PLT. ❑ Method of Disposal -i <br /> Distance to <br /> nearest: Well Foundation Property Line d <br /> f <br /> LEACHING LINE ❑ No. b Length of lines 1 T I length/size <br /> FILTER BED 0 Dietsce U; <br /> nearest:r Wall Property Line <br /> i ir <br /> -SEEPAGE PITS I th Wuapber '- <br /> SUMPS CI Distance to nearest: Well" — undiitian- _Property Line <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 /> i 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 shell not <br /> employ any parson in au6. -Manneras to become subject to workman's compensation laws of California." Contractors 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 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant c all Zutfed i s do s. Complete dr mg on reyp/rusisiiddee. <br /> Signed itle: ---� ----� Date: <br /> DEPARTMENT USE ONLY <br /> Application Accepted by �.lu�r�..�{ Data — Z- Area <br /> Pit or Grout Inspection by Date Final Inspection by Date0�- <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County'Public Health Services - ` <br /> # Environmental Health Permit/Services <br /> l] 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 Q <br /> INFO <br /> EEE AMOUNT DUE AMOUNT REMtrrEo CASCV If RECEIVED BY DATE PERMIT"NO. <br /> r ' EM14.26 tiv.,,msiS l t,�� ldl 9�-- 3 S <br />