Laserfiche WebLink
APPLICAT 4 FOR PERMIT <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 /> PERMIT EXPIRES 1 YEAR FROM DATE I*SUED <br /> (Complete in Triplicate) <br /> Appkkcstion 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. E11 �+ <br /> Job Address City L t__F i Lot Size/Acreage <br /> 1 <br /> w is Ne <br /> n�� d; 1 1r i T:)y PP/AddressAffZPhone <br /> 00 <br /> L Q <br /> t t less DOkix6 , nee No, hone-1 — <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEME T F DESTRUCTION 0 Out of Service Well Cl <br /> PUMP INSTALLATION ❑ SYSTEM REPAI 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 /> L7 I dustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> mastic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications a] <br /> /l'1 Public Cl Other fl Delta Depth of Grout Seat Type of Grout .� <br /> I I Irrigation —Approx. Dept i I asternace Soul Installed by <br /> Repair Work Done L] Type of Pump H.P. Stats Work Don _ JW <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Tiller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIRIADDITION I I DESTRUCTION I t iNo septic system permitted if public sewer is f <br /> available within 200 feet.) <br /> Installation will serve: Residence__`__ Commercial— Other <br /> Number of flying units: Number of bedrooms <br /> Character of soil to a depth of 3 fest: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal (� <br /> Distance to nearest: Well Foundation Property Line l <br /> LEACHING LINE L1 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 /> 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 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following: "I csrt hat 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 /> l � <br /> The applican s call for all sp*ct' ns. Complete drawing on reverse e.+ <br /> Sig Title: Date: <br /> F R DEPARTMENT USE ONLY a 1 <br /> Application Accepted by Date -9 Area p 2 L <br /> Pk 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 Permit/Services <br /> 445 N San JoaQuin,P--O Box 2009, Stkn, CA 95201 <br /> FEE -INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY GATE PERMIT NO. <br /> • EH 13.24 044 1/9 51 /Y�ff (�/� r�j�jJ�� Q ^ QF �} <br /> EH 14.6 <br />