Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 10 ENVIRONMENTAL HEALTH DIVISION / w' <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O 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 /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulation p of San <br /> Joaquin County Public Health Services. / �.ry� /� n�//� <br /> �f,Z 7� �S �Jy / K�` �� -1'yG-JLot Size/Acre <br /> Job Address City age <br /> Owner's N r y Address J� Phone <br /> Contractor l Address icense NY,]—;,I V-I Ph.r aid <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL R LACEMENT F) DESTRUCTION ❑ Out of Service Well Cl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Cl OTHER ❑ 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 CONSTNUCTION SPECIFICATIONS Y <br /> 11 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> r) Domestic/Privsta ❑ Gravel Pack O Tracy Type of Casing_ Specifications <br /> FI Public I-1 Other 1-1 Delta Depth of Grout Seal Type of Grout <br /> 11 Irrigation __Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump N.P. __ State Work Dona _ <br /> Well Destruction ❑ Well Diameter Sealing Material f1 Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION R DESTRUCTION 11 (No septic system permitted if public newer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> I <br /> Number of living units: 4— Number of bedrooms i <br /> Character of soft to a depth of 3 fest: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity.614WO. No. Compartments <br /> PKG. TREATMENT PLT. Cl / Method of Oispospl <br /> Distance to nearest: Well Q / Foundation 1 Property Line _ <br /> LEACHING LINE Cl No. 6 Length of lines — Total length/size _ <br /> FILTER REO n Distance to nearest: Well fQD Foundation _ Property Line .el� / <br /> SEEPAGE PITS1 1 Depth Size _ � Numbgr <br /> SUMPS LI Distance to nearest: Well _ �� Foundation_ PrOP64 Lina <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, at to 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 isaur 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, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mus a for all requir I spe, ions. Complete drawing on reverse side. <br /> Signed Title: &a". - Date: <br /> FOR EPA TMENT USE ONLY <br /> Application Accepted by `, - Date Arse <br /> Pit or Grout Inspection by Data Final Inspection« �r�d' Date 10• m �� <br /> i <br /> Additional Comrnegis: / i r <br /> Applicant Retu). all copies to: San Joaquin County public Health Services SZ <br /> I Environmental Health Permit/Services <br /> - —' 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEt <br /> INFO AMOUNT C{t1E ­4MOUNT REMITTED CK II RECEIVED BY GATE PERMIT NO. <br /> EH ,3 24 I , �-� S y <br /> FH t4.as AEV. V� ( r- 3v) ��l -� UJ ( �� <br />