Laserfiche WebLink
A_ <br /> APPLICATION FOR PERMIT PAYMENT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES RECEIVED <br /> ENVIRONMENTAL HEALTH DIVISION NOV 161992 <br /> P O BOX 2009, STOCKTON, CA 95201 SAN JOAQUIN COUNTY <br /> (209) 468-3447 pL;&t_iC HEALTH SEgVICES <br /> f:i,.v=iR',MENTA.I_HEMM u1UIS:ON <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 /> application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> i <br /> Job Address 190 4J' lu City Lot Size/Acreage <br /> Owner's Name ddress (� Phone <br /> - Contract <br /> Addres� &-w �L.icense Njk� --- PhonA35 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 1_1DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR fad OTHER C3Monitoring Well �� <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 /> 0 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> -.� <br /> bler <br /> omesticIPrivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ..� <br /> ID Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout <br /> Ml Irfigauon — Approx. Depth 0 Eastern t Surface Seal Installed by Q <br /> Repair Work Dona ,Type o! Pump H.P. l��r State Work Dona <br /> ra <br /> Well Destruction O Well Diameter Sealing Material i Depth <br /> Depth Filler Material & Depth ` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION I-] DESTRUCTION ei INo septic system permitted if public sewer is <br /> available within 200 feet.] <br /> Installation will serve: Residence __ Commercial Other. <br /> Number of living 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 /> PKG, TREATMENT PLT.❑- r Method of Disposal <br /> Distance to nearest: Well Foundation Property Line m <br /> LEACHING LINE ❑ No. & Length of linea Total length/size <br /> FILTER BED 171 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS It Depth Size Number <br /> SUMPS LI 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 accardance 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 shall not <br /> employ any person in such manner as to become subject to workman's compensation taws of California." Contractor's hiring or sub-contracting signature <br /> sonifies the following: 1 certify that in the performance of the work for which this permit is issued, I shalt employ persons subject to workman's compensa• <br /> tion laws of California." <br /> The applicant must Spill tppr all requir pections. Completer drawing on eras side. <br /> SignedTitle: Date: r� <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <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 O B 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED tKRECEIVED BY DATE PERMIT'NO. <br /> INF(O� y►� r <br /> . EH 13.24IrIEV.I/1%5) V� Lf s.alp �a '[�� !? <br /> (:H:a.16 <br />