Laserfiche WebLink
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 x <br /> �tG'RYTrI' RXPIRES 1 YTAH I�ROd DATE ISSUE <br /> (Complete la Triplicate) <br /> Application Se hereby <br /> made San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application to made in certtjrllance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban <br /> Joaquin County Public Health Services. k <br /> City-52 <br /> Lot Size/Acreage <br /> Job Address qS <br /> t !r ddress I r � - � Its.- Phone <br /> Owner's Na J � <br /> r <br /> s Its a- r C <br /> �-P <br /> ntractor YNA <br /> Address L+cense No. <br /> WELL REPLACEM T �} DESTRUCTION ❑ Out of Service Well <br /> CA <br /> _ E OF WELLlPUMP: NEW WELL ❑ OTHER ❑ I Monitoring Well C1 i <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK .SEWER LINES ._._.�--W— <br /> DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> L71 Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Specifications - <br /> [J Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing <br /> M Public <br /> Cl Other ❑ Delta Depth of Grout Seal Type of Grout <br /> C.i Irrigation —Approx. Depth ❑ Eastern Surface Seat Installed by <br /> Repair Work Done {]`...-Type of Pump H,P• State Work Done_ <br /> Well Destruction D Well Diameter <br /> Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> system permitted <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/AODITION IZIP DESTRUCTION availabte'within 200 feet.) if public sewer is P <br /> Installation will serve: Residence — Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of *oil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK 0 Type/Mfg Cs cit No. Compartments <br /> PKG, TREATMENT PLT. ❑ fA Method of Disposal <br /> Distance I no rest: W II un Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED D Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br />' DISPOSAL PONDS D <br /> I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, stats laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature cenifies 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 shall employ persons subject to workman's compensa <br /> tion laws of California." <br /> + Thapplicant ust call for all require In tions. mplete drawing on reverse side. <br /> If �7 ' d <br /> S;g�ne Date: <br /> i <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by Date <br /> / � � Area <br /> Pit or Grout Inspection by Date Final Inspection by Date L <br /> I <br /> i Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT AEMI rt EO C>< RECEIVED By DATE PERMIT N0. <br /> INFO /�T CA5H r f <br /> rEH13•241REV.r/wsl �c..� f � U y"L�-r'� <br /> i EM',416 1 � r � <br />