Laserfiche WebLink
APPLICATION <br /> fi <br /> n SAN JOAQUI.N COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 /> ry <br /> application is made in compliance with San Joaquin County Ord1nance No. 549 and 1862 and the Rules and Regulations of Ban <br /> Joaquin County Public Health Services. <br /> l City t Size/Acreage <br /> .lob Address - �� ,G!S <br /> Owner's Name <br /> Address 7 honeZ <br /> Contract Addres <br /> License 14�--Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT I 1 DESTRUCTION D out of service Well e well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ <br /> MonitorDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f7 Industrial D Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> p Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> I"1 Public Cl Other fl Delta Depth of Grout Seal <br /> Type of Grout <br /> l I Irrigation —Approx. Depth I I Eastern Surface Seat Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Dona <br /> Well Destruction O Well Diameter <br /> Sealing Material & Depth <br /> Depth Filler Material i Depth tT <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 I DESTRUCTION Iva septic system permitted if ptrbtiC"serovar is t+ <br /> ailable within 200 feet,y <br /> Installation will serve: Residence>!�. Commercial _ Other <br /> Number of living units: _J.___ Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity` Na. Compartments <br /> PKG. TREATMENT PLT. ❑ s- ` Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING, LINE ❑ No. & Length o s l� Total length/size <br /> FILTER BED 0 Distan nearest: Well Foundation Property Line <br /> SEEPAGE PITS l�I Depth Size Number <br /> SUMPS / Ll Distance to nearest. Well Foundation Property Line <br /> DI SAL PONDS 11 <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 /> 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." 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 shall employ persons subject to workman's camp ensa <br /> tion laws of California." <br /> The applicant mu c II for ail r ire2in" ions. C9PPI drawing on r se side. <br /> Signed ' �`yu Title: Date <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date ! Are <br /> k <br /> Pit or Grout Inspection by Date Final Inspection by Dater —t`-2 <br />± Additional Comments: <br /> Applicant - Return all copies to. San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> se FEE AMOUNT Dt}E AMOUNT REMITTEDSH RECEIVED BY DATE PERMIT'NU. <br /> f=- <br /> INFO <br /> . EN 13-24 tAEV.I n 51 <br /> FH 14-16 <br />