Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> F1 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> �F1 (209) 468-3447 <br /> 1 <br /> REMIT -EXPIRES 1 YEAR ROM DATE ISSUED <br /> F1 (Complete in Triplicate) <br /> Application in hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application in 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 /> t � �j I <br /> Job Address .1 1 �� �+. T'" e �" City Lot Size/Acreage r`e�5 <br /> Owner's NameAddress A7 a C'/r/�E� � � � Phone ►t <br /> /ala L P"&," A F r����o�� <br /> Canlrattor Address. _ License No, Phone <br /> TYPEOF WELL/PUMP; NEW WELL WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ❑ <br /> Fi PUMP INSTALLATION e SYSTEM,REPAIR ❑ OTHER ❑ Monitoring Well G7 <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE <br /> R FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS <br /> FINTENDED USE TYPE OF WELL PROBLEM AREA. CONSTRUCTION SPECIFICATIONS Fr <br /> n Industrial 1 ❑/Open Bottom ❑ Manteca Dia, of Well Excavation__ Dia. of Well Casing V0omestic/Private ISI Gravel Pack •ar_r___ Type of Casin L <br /> g p� Specifications <br /> M Public 1.1 Other 0 Delta of Grout f Type of Grout \ <br /> C! Irrigation ppro><. Depth ❑ Eastern Surface Ss Installed <br /> f Repair Work done [] ype of Pump �_ H.P. [ate Work Done <br /> Weis Destruction Well Diameter 6 eine Material �Q <br /> Depth '^ Filler Material i h <br /> { TYPE, OF SEPTIC RK: NEW INSTALLATION❑ REPAIRIADDITIO ESTRUCTION 11 (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: a Other <br /> j Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> FSEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> 1 PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> F1 LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation . Property Line <br /> ,1 <br /> SEEPAGE PITS 11 Depth Silo Number <br /> SUMPS Ll Distance to nearest: Well Foundation_ . _ Property Line <br /> DISPOSAL PONDS ❑ <br /> I 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 /> F, Home owner or licensed agent's signa[ure certifies the following; "I cenify 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, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required ins ttions. Complete drawing on reverse side. <br /> Signed t `^��� '� ......_._� Title: S.?/,',s " _S&v Date: I0 ' � (��✓ <br /> FOR DEPA bLT USE.ONLY <br /> Application Accepted byR Date_ Area <br /> Pit or Grout Inspection by Date Final Inspection b Datq <br /> �r <br /> ! <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 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE <br /> L INFO OUN7 DUE AMOUNT REMITTED C.A.�SPH RECEIVED 81' DATE PERMIT'NO. <br />