Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC REALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> LUIT EXPIRES 1 YEARI?ROI�DATE ISSUED <br /> (Complete in Triplicate) <br /> Application 1s hereby tnade.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. p <br /> Job Address �" City Lot Size/Acreage <br /> Owner's Name--7OM 2�� <br /> _Address Phone <br /> Contractor] � Addres � 7 Licen <br /> f TYPE OF WELL/PUMP: - , NEW WELL D WELL REPLACEMENT P. DESTRUCTION 0 Out of Service Well 0 <br /> ^ <br /> PUMP INSTALLATION ❑ i SYSTEM REPAIR �ElI OTHER ❑ Monitoring Well [7 <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 /> n Industrial D Open Bottom D Manteca Dia of Well Excavation Dia of Well Casing <br /> U Domestic/Private 0 Gravel Pack- O r <br /> Tracy Type of Casing _Spec 11 <br /> M Public !.1 01har (] DeltaDepth of Grout Seal 'Type of Grout <br /> 0 Imoation _ Apfxox, Depth ❑ Eastern Surface Saul Installed by <br /> 1 � - <br /> •Repsir Work Done 0 Type of Pump H.A. State Work Done <br /> Well Destruction O Well Diameter Sei ling,.Material i1 Depth - <br /> Depth Filler Material 4 Depth <br /> {' TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION DESTRUCTION Ci (No septic system permitted it public sewer is <br /> _ available within 200 feet.) <br /> "Installation'w4l serve:, Residence Commercial — Other <br /> Number of living units: —jL-- Number of bedrooms / <br /> Character of soil to a depth of 3 feet: � �-_-_ Water table depth <br /> SEPTIC TANK,C__�>5Tr0 Type/Mfg ; Capacity No. Compartments <br /> PKG. TREATMENT PLT. C1 Method of Disposal <br /> 1 Distance to nearest: Well Foundation Property-Line - <br /> LEACHING LINE No. & Length of lines 021 Total length/size,�i <br /> FILTER BED Ll Distance to nearest: Well Foundation r,�� ' Property Line ,lila � <br /> SEEPAGE PITS XI Depth s � Size Lel I�ihr Number <br /> SUMPS LI Distance to nearest: Well /65 r Foundation .� Property Line <br /> DISPOSAL PONDS ❑ t <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 ' 11 <br /> Home owner or licensed agent's signature cenifies 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 /> V 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 must call for all required inspoctioiiIts. Cgmplete rawing on reverse side. <br /> Signed, Title: �� ��—'( _ Data: <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date v Area <br /> 1 / <br /> P or Grout Inspection by, ate Final Inspection b ate <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 1 1 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201FIE <br /> INFO AMOUNT DUE AMOUNT REMITTED I CK CASH RECEIVED BY DATE PERMIT NO. <br /> EH 13-24IREV.I/- 7 .r„ <br />