Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> h PERM T. R IRES 1 YRU FROII� D T S <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 i <br /> application is made in ceapliance with San Joaquin County Ordinance No. 549 and 1802 and the Rules end Regulations of San <br /> Joaquin County Public Health Services. JCY <br /> Job Address �• �` Cityt Size/Acreage <br /> IWL <br /> Owner's Name —_ r "�L 1'c`�9ni[G�T Address c- l Phone <br /> 5 <br /> Contractor ��'i! Address License No.ZkassL- Phone <br /> TYPE OF WELL/PUMP: NEW WELL -WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER ❑ Monitoring 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 Y <br /> C1 I ustrial ❑ 0' n Bottom_-- Cl Manteca pia. of Well Excovat' Dia. of Well Cas_in <br /> a <br /> DomesticlPrivate Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> 1'l Public / (-1 Other 171 pelta Depth of Grout Seal Type of Grout,&"2—f;,,#, <br /> I I Irrigation '01M <br /> Approx. Depth )" 'Eastern Surface Seal Installed by <br /> Repair Work Done I> Type of Pump H.P. State Work Done \ <br /> Well Destruction ❑ Wail Diameter Sealing Material 0 Depth <br /> Depth Filler Material i Depth <br /> 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION I,I DESTRUCTION I i lNo septic systerri permitted if public sewer is <br /> p . �avertable within 200 feet.) <br /> Installation will earn: Residence—. Commercial_ Other -� <br /> Number of living units-. Number of bedrooms <br /> Character of soil to a depth of 3 fest: I <br /> Water table depth <br /> SEPTIC TANK. <br /> ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> i; <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED Cl Distance'lo nearest. Well Foundation Property Line <br /> f <br /> SEEPAGE PITS 11 Depth Size Number i <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 r <br /> rules and regulations of the San Joaquin county <br /> Home owner dr licensed'pgent'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 laws of California." Contractor's hiring or sub-contracting signature <br /> cortifias 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 /> 1 11 <br /> The applicant/must all for_ll req L�apqclions. Complete drawing on revered a'ida. <br /> signed -fitsi' / / � <br /> title: Date: r <br /> r <br /> FOR DEPARTMENT USE ONLY J� <br /> Application Accepted by ~�1- Date_45Z-- _ Area n 2-`111 R ' <br /> Pit or rout nspection by Date ? Final Inspection by Date iP <br /> Additions Comments: Il t) <br /> Applicant - Return all 1-pies to: San Joaquin County Public Health Servicers <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMCASH OU T REMITTED <br /> INFO K ECEIVEp BY DATE PERMIT'NO. <br />« EH 11 .74111EV.i/sal �q rjD <br /> t <br /> EH 47a y / 6! <br /> . i <br />