Laserfiche WebLink
i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION tiQu 7-� <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 �.1���, . 0-11P <br /> 2IMI3: EXPIRES l YEAR IROM DATE ISSUED t <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 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 Z Cit,, O` dot Site/Acresge� /�Z- d ' <br /> Owner's Name Q '--I �� 11ddress 2" e�� Cam` __ Phone (� <br /> KConlraci Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION ❑ Out of Service Well L� � <br /> PUMP INSTALLATION❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> l FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL -PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> CI Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications <br /> L Public Ia Other ❑ Delta Depth of Grout Seat Type of Grout <br /> M IrriUation Approx. Depth Cl Eastern Surface Seal Installed by <br /> Repair Work Done IJ Type of Pump H.P. State Work Done <br /> Melf_Dastruction O Well Diameter Sealing Material i Depth <br /> Depth x Filler-Material-i Depth <br /> TYPE-'OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADOITION M DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feat.) ; <br /> Installation will serve: Residence^ Commercial— Other <br /> Nc <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg ;Capacity No. Compartments <br /> PKG. TREATMENT PLT,0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> i <br /> LEACHING LINE 0 No. 8.Length of lines Total length/size <br /> FILTER BED El Distance to nearest: Well Foundation Property,Line <br /> SEEPAGE PITS I I Depth Sire Number <br /> SUMPS Ll 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 Sari Ji iquin Cour:ty - '- — " i <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 sub-contracting signature <br /> certifies the following: "I certify that in the performance of t ork for which this.permit.is'issued;•l shall employ persona subject to workman's compensa- <br /> tion laws of California." <br /> he applicant t r eq ins tions, C plate drawing on reverse side. <br /> igned Title: — .�Af�-'� - r Date: <br /> \\ I <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by OAD`1. . -� Date Z Area L <br /> Pit or Grout Inspection by Date Final Inspection by �� Date n <br /> Additional Comments: <br /> Applicant - Bet= 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 86201 <br /> FEE <br /> INFO AMOVNT DUE AMOUNT REMITTED CASH RECEIVEO BY DATE AERMIT NO. <br /> . EH 13-24 TREY,rihsl <br /> 2e <br /> , t 0� l�}'a 1931 <br /> EH <br /> 14 24 <br /> I1 <br />