Laserfiche WebLink
APPLICATION FOR PERMIT <br /> " Aw <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERYICTS `� ,}, -a! <br /> ENVIRONMENTAL HEALTH DIVISION L-.a <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468--3447 MAY 9 �' <br /> ERMIT A$�„YEAR FROM DATE ISS� _nN''llRO��N��ryi�iTAt. HEA 7H <br /> (Complete in Triplicate) PEr T/SERVICES <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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health. Services. <br /> Job Address w" City Lot Size/Acreage <br /> i <br /> Owner's Nam s /LVYI.�i+� .tt.�--- Address ''^A`— Phone <br /> C <br /> Contractor Address16dbj_eU=_ X31 License No d L—Phone <br /> TYPE OF WELUPUMP: NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well Cl <br /> PUMP INSTALLATION � SYSTEM REPAIR � OTHER ❑ Monitoring Well C7 <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-} In nal ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing <br /> omestic/Private 0 Gravel Pack n Tracy Type of Casing Specifications <br /> M Public I'l Other 0 Delta Depth'of Grout Seal Type of Grout <br /> CJ Irrigation Approx. Depth C1 Eastern Surface Seal Installed by <br /> Repair Work Done 4Y Type of Pump H.P. Q om_ State Work Done <br /> Well Destruction 0 Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIRIADOITION Ll DESTRUCTION CI (No septic system permitted if public sews( is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth J <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.G7 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. 3 Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number A <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby comity 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 /> Home owner or licensed agent's signature certifies the following: "I comity 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 /> The applicant mu 11 requireq-inspections. Complete drawing a ever*@ side. <br /> Signed X Title: Dater <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by Date / Area <br /> Pit or Grout Inspection by Date Final Inspection by Data <br /> 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 CK 9 <br /> INFO AMOUNT DE AMOUNT REMITTED AASH RECEIVED BY DATE PERMIT'NO. <br /> . EH 134 iilEV, <br />