Laserfiche WebLink
APPLICATION FOR PERMIT <br /> 4 , <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 /> 'PEWIT-EXPIRE 1 XM FROM DATE U <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 ecavpliance vith.San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> i c :r /Acreage r <br /> Job Address ' City <br /> Owner's No—.Dc-,, f Address Pfione P <br /> Contractor -, Address License No. C Phon <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLXCEWENT rl DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑. OTHER ❑ Monitoring Well C7 <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 /> 0 Industrial C1 Open Bottom 13 Manteca Dia. of Well Excavation Dia. of Well Casing <br />' [I Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications SQ <br /> ('1 Public 1-1 Other 1-1 Delta Depth of Grout Seal Type of Grout <br /> I I Iffigation _Approx, Depth l I Eastern. Surface Said Installed by ^ <br /> Repair Work Done U Type of Pump H.P. i State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depthilk <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION :.DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other �� t <br /> Number of living units: .. Number of bedrooms ° <br /> f'fl\ I <br /> Character of sola to a depth of 3 feet: Water table depth <br /> k SEPTIC TANK. O Type/Mfg Capacity No. Caflpartments �J7 <br /> PKG. TREATMENT PLT.Ll Method of Disposal <br /> Distance to nssrest:': Well Foundation Property Line <br /> f r � <br /> u <br /> LEACHING LINE No. b Length of lines LPaall, otal length/size e <br /> FILTER BED. Cl Distance to nearest. a WeII Foundation P;roperty,Lind' <br /> a <br /> f <br /> r SEEPAGE PITS 11 Depth —Size NumbeP—: r f <br /> 5UMPSLl Distance to nearest: WeII . Foundation .Property Lira` <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work wlil be donelin accordance v4Rh San`Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County { _ = 1 '' <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 shell not <br /> ( employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring.oi.sub-contracting signature <br /> i certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall srmploy persons subject to workman's compenss- <br /> lion laws of California.' _ .w.�..h- <br /> T fi nt 9qpt call for all r tion Complete drawing on re er side. <br /> Title: Data: <br /> Signed -�— <br /> EOR DEPARTMENT USE ONLY <br /> CIR <br /> Application Accepted by ' Date Area M <br /> Ph or Grout Inspection by _ Date Final Inspection by Dat <br /> Additional Comments: <br /> Applicant Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health,Permit/Services <br /> r 445'N San Joaquin, Box 2009, Stkn,-QA 95201 <br /> FEE AMOUNT DUE <br /> REMITTED 1C Ft RECEIVED SY O PERMIT'_r. <br /> INF zaL <br /> . EH 13-24 IREV.IiR5)A 11 L� I <br /> EH 14.70 <br />