Laserfiche WebLink
�/ �f3— wur <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 44��efey <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-34$r, O <br /> PERMIT EXPIRES 1 YEAB EROR , DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in ccWliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address �� '� City LL Lot Size/Acreage <br /> Owner's Name -i Y/ / ► ! L7- LxAddrass -4- Lf"/ Phone <br /> �? <br /> • COnllaclor �rT�,� Address3� �e NtI.�._� €, ,�Phane J <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Ca DESTRUCTION ❑ Out of Service Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER Q Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK _SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS + <br /> E1 Industrial C;&%pen Bottom O Manteca pis. of Well Excavation Dia. of Well Casing <br /> C*aomeslic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public 1:1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> 0 Ir+igation _„-,_-Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done LJ Type of Pump — -_ H.P. State Work Oona <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION D .REPAIR/ADDITION M DESTRUCTION G lNo septic system permitted if public sewer is <br /> available within 200 feet.) O <br /> Installation wRl server Residence— Commercial_ Other <br /> Number of fivinq 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 /> PKQ. TREATMENT PLT.C1 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. 8 Length of lines . . Total length/size � P <br /> FILTER BED n Distance to nearest: Wolf Foundation Property Line <br /> SEEPAGE PITS I I Depth Sire Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line ,C <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 V <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 shell not ] <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature 13 <br /> certifies the following: "I certily that in the performance of the work for which this permit is issued.I shall employ persons subject to workman's eompenu- <br /> don laws of California." ; <br /> The mpp=tlll f ryall required inspections. Complete drawing on reverse side'.Signed --,...... Title:Lam!, _ Date:• <br /> �2,F5 DEPARTMENT USE ONLY <br /> y C <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Oat��� <br /> i <br /> Additional Comments: II <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 BOR 2009, STOCKTON, CA 85201 <br /> IEEENFO AMOUNT DUE ;AMOUNT rtEMtruo CASH <br /> RECEIVED BY DATE PERMWNO. <br /> . E+i'•'..m,rlty.�,�„ v.�a <br />