Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 1 <br /> PERMIT_EXPIRES 1 YEAR FROM DATE ISSUED ; <br /> (Complete in Triplicate) <br /> Application is hereby, made to Ban Joaquin County for a permit to construct and/or install the cork herein described. This <br /> application in Stade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San +k <br /> Joaquin County Public Health Services. n. <br /> Job Address Q City Lee& Lot Size/Acreage <br /> Owner's Nalei <br /> - --Address _ --- P`hooneCDntraClDr dIh Address License No. Yr- phone � -27 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPL EMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTE REPAIR ❑ OTHER 0 Monitoring Well O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> Y}INTENDED,USE TYPE OF-WELL -PROBLEMAREACONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ; ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1 <br /> Cl Domestic/Private �❑ Gravel Pack _Z]•Tracy - Type of Casing_ Specifications <br /> 11 Public # [I Other n Delta `d -Depth of Grout Seal Typa o1 Grout <br /> 1-1 Iriibation f _Approx. Depth I I Eastern .Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. 1 State Work Dane <br /> ' "' Sealing Nateiria.li Depth <br /> _ O <br /> Well D { Weli Diameter y <br /> Depth FillerS Material i.Aepth } . <br /> I <br /> TYPE OF SEPTIC WORK,. NEW 1NSTALLAT1ON —REPAIR IADDITION 01 DESTRUCTION I 1 INo septic system permitted if public sewer is -� ) <br /> r ""'"" available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other a <br /> Number of l4iny urines:_ Number of rooms <br /> i Water table depth I <br /> Character of.so#to a depth of 3 feet: <br /> SEPTIC TANK. ❑ Type/Mfg Capacity/ d - No. Compartments i <br /> PKG. TREATMENT PLT.❑ r Method of Disposal j <br /> Distance to nearest: Well.^ Foundation ­7 Property Line f <br /> iC <br /> LEACHING LINE C1 No. A Length of lines - 6 Total lengthtsize <br /> FILTER BED ❑ Distance to nearest: Well Foundation _ __ Property Line ��-e, <br /> SEEPAGE PITS 11 Depth -S, Size m�.T ��-- c� Number <br /> SUMPS LI Distance to nearest: Well Foundation d�-�--- Property Line ZO <br /> DISPOSAL PONDS ❑ `= <br /> 1 hstaby certify that I havi prepared this application and that the work will be done in accordance with San Joaquin county ordinances, statelaws, an <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 sh <br /> employ any person in such manner as to became 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.shali employ persons subject to workman's compensa- <br /> tion laws of California." <br /> ..., .may--.».._. .- • __:.. ... ��. -------^ .- . <br /> The app4cont` r all ct s. Complete drawing on reverse side. <br /> Signed �:— Title: _ Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date `�� 93 Area Q <br /> �3 I �r ✓ <br /> �3 or Grout Inspection by Date r� Find Inspection by is <br /> i Additional Comments: T <br /> f 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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> l <br /> INFO f� �j q CASH y�/�� <br /> . EH M24(REV.I/FS) /t!.' � � " �V (� � T,� F-1/�3 J O V <br /> i EH 14.36 1 <br />