Laserfiche WebLink
APPLICATION FOR PEkMIT <br /> yY„ 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 /> I. <br /> PERMIT E%PIRES 1 YEAR FRQM DATE ISSUED i <br /> (Complete in Triplicate) <br /> Application is hereby made to Sea,Josquin County for a permit to construct and/or install the vork herein described. This <br /> application a mar de in compliance'vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin Coun Pub is Health rv4ce <br /> t�^J City Wt Size/Acreage <br /> Job Address <br /> Owner's Name 4�e <br /> AddressPhone <br /> Contractor ""' sl�� nse No. 991 Phone•✓ <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENTn DESTRUCTION ❑ out roar Service well <br /> Well <br /> ❑ <br /> PUMP INSTALLATION' ✓ SYSTEM REPAIR' ER_Q ,,._ O <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 /> ❑ Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> '' Type of Casing- Spedlications. - - <br /> pomesticlPriwte ❑ Gravel Pack ❑ Tracy 9- , <br /> /I'I Public n Other f f-1 Delta Depth ofGrout Seal Type of Grout <br /> I I Irrigation <br /> _Approx., Depth I 1 Eastern Surface Seat Installed by _ <br /> H.P. State Work Done * r <br /> Repair Work Done Type of Pump �5 <br /> 8ea11xtg Material i Depth a� •� - /'j� ���1 Well Destruction ❑ Well Diameter rt <br /> Depth Tiller Material i Depth _/E , -� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION i I INo septic system permitted it 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 sol to a depth of 3 feet:I Water table depth <br /> SEPTIC TANK .,0 Type,'Mfg y Capacity-_ No. Compartments <br /> PKG. TREATMENT PLT.D Method of Disposal <br /> Distance to nearest: well Foundation Property Line <br /> LEACHING LINE ❑ No. IN Length of lines Total length/site r— <br /> FILTER BED ❑ Distance,to nearest: Well Foundation Property Line Y <br /> SEEPAGE PITS I I Depth "l Size Number. <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ I . <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Sano-Joaquin county.ordinances;'state,laws, and <br /> rules and regulations of the San Joaquin CLounty <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 laws of California."Contractor's hiring or subcontracting signature n <br /> certifies the following:f'I cartify.that in the perlormonce of.the work for which this permit is issued, I shall employ persons subject to workman's compensa �j <br /> tion laws of Cali nia." c <br /> The appliean T ` t uil for r ins tions. gomplete drawing o rev side. <br /> I <br /> Sip a` Title: Date: <br /> t <br /> FO� EPAfITMENT USE ONLY <br /> Application Accepted by Date Area I <br /> Pk or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> r - <br /> .Applicant - Return all copies to: San Joaquin County Public Health Services 'e <br /> Environmental Health Permit/Services r <br /> 445 N San-Joaquin Box 2009, Stkn, CA 95201 <br /> I fi <br /> FEE + <br /> INFO <br /> AMOUNT ptiE AMOU T REMITTED t:K RECEIVED BY DATE PERM17'NO. <br /> l a EH 13-24 IREV.I/A5! <br /> --� -� <br /> E!1 14-Ul� <br />