Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> VRAR <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 ccowliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County PublicHealthSSer/vices. ) ,f 1 / 6 f <br /> Cityi4 �dr� Lot Size/Acreage ( C <br /> Job Address ._ 1 a <br /> ,r��liJ � f� ^ Address ��3 Phone <br /> Owner's Name � � . <br /> Al <br /> 0�(/Y�D - Address License No. Phone <br /> Cont+aActor -. Well LI <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT I7 DESTRUCTION Out MonSitoring Well f7 <br /> PUMP INSTALLATION ❑ / SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER'LINES� DISPOSAL FLD. PROP. LINE <br /> f FOUNDATION AGRICULTURE WELL, OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF W£Ll PROBLEM AREA CONSTRUCTION SPECIFICATIONS Oia, of Well Casing <br /> 0 Industrial D Open Bottom ❑ Manteca Dia. of Well Excavation't. —Specs i <br /> If+cations <br /> U DOmestictPrivate ❑ Gravel Pack n Type of Casing Tracy Type of Grout <br /> I'1 Other 0 Delta Deprth of Grout Seal <br /> ID PubliC r� t <br /> trripanon Do�oApprox, Depth ❑ Eastern Surface Seal installed by r t <br /> Repair Work Done U Type of Pump H.P. ,� StatWor Don <br /> _ <br /> Sealing.Naterial i Depth <br /> v Well Destruction ❑ Well Diameter Filler Material A Depth <br /> Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION❑ REPAIR/ADDITION Ll DESTRUCTION C.3 iNo septic system perrnittscjf public sewer is <br /> -available within 200 feet.l t <br /> installation will serve: Residence"—. Commercial _ri Other <br /> s <br /> I� Number of living units: z Number of bedrooms <br /> 7 <br /> Character of soil to a depth of 3 feet: Water table depth s <br /> SEPTIC TANK ❑ Type/Mfg t. Capacity No. Compartments <br /> PKG i TREATMENT PLT. Cl>-� <br /> Method of Disposal <br /> f Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. 13 Length of lines Total length/size <br /> k FILTER BED n Distance to nearest: Well Foundation Property Line <br /> w <br /> } t �> I <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well I Foundation Property Line <br /> DISPOSAL PONDS ❑ t <br /> I hereby certify that I have prepared this application and that the work wZII be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County 1 <br /> k Home owner or licensed agent's signature certifies the following: "I certify,that in the performance of the work for hich this permit is issued, I shall not <br /> employ any person in such manner as to become subject to work man's,compensation laws of California," Contractor's hiring c 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 Isws o1 Calilornl ."� <br /> The appticant i r 70 <br /> Z11fq red inspections, Complete drawing on reverse'side. fi i 1 <br /> ' �„Blai U Date: / <br /> Signed Title. <br /> i <br /> [ F R DEP MENT USE ONLY <br /> f Application Accepted by Date A�9 Area <br /> + Date ° Finaltn:pection by Date T <br /> Pit or Grout Inspection by <br /> k — <br /> Additional Comments: 1 <br /> ` Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 85201 pt <br /> tf <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEiVEA BY DATE PERMIT N0. <br /> INFO <br /> . EM 53.24IREV.I I C9.G, C? f i <br /> EN 14.2e <br />