Laserfiche WebLink
ca <br /> s <br /> 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 /> PERMIT EXPIRES 1 YEAR FROM DATE I$SUEP <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 cceWliance vith San Joaquin County Ordinance No. 549 and 1862 Fed the Rules and RegulAtions of San <br /> Joaquin County Public Health Services. <br /> I � <br /> l I <br /> Job Address Cit Ut Size/Acreage. f <br /> ddre r ' -'Phone- <br /> _ 's Na -" <br /> re o} �C7�V <br /> C r <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT O DESTRUCTION ❑ Out of Service well ❑ <br /> Cr2 Monitoring well <br /> PUMP INSTALLATIO } SYSTEM REPAIR:-C3-,�.a Y OTHER 0 f❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES DISPOSAL FL'0 PROP. LINEA ✓_ . <br /> FOUNDATION— AGRICULTURE WELL OTHER WELLPITS/SUMPS " y <br /> :t <br /> INTENDED USE TYPE OF WELL. PROBLEM AREA° CONSTRUCTION SPECIFICATIONS— <br /> C1 I ustrlal ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wel!Casing a " <br /> stic/Private L1Grav*Pack _j 0 Tracy i Type of Casing_ — Specifications <br /> .... T - <br /> l'I Public Cl Other F1 Delta Depth of Grout Seal t Type of Grout t <br /> I I Irrigation _Appr4x--DNZ <br /> rface Said Installed by 19 <br /> Repair Work Done 0 Type of Pump H.P. ti. State Work Done I I <br /> Well Destruction ❑ Well Di 1 . ing e-, <br /> Well Depth 1 <br /> Depth driller Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted H i <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: Number of bedrooms i f j <br /> i <br /> Character o1 roil to a depth of 3 fast:' 1 - — --�---- -�-- - '---Water,tutble-depth— <br /> SEPTIC TANK ❑ Type/Mfg Capacity y f Nd*Compartments <br /> PKG. TREATMENT PLT. 0 Y Method of Disposal <br /> 3 <br /> Distance to-nearest: Well..-----------... Foundation T.-..--T.-..Property-L-ine ; <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> 3 <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I herebycertify that I have I <br /> fy prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stela laws, and a <br /> rules and regulations of the San Joaquin County I <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 nner as to become subject to workman's compensation laws of California." Contrector's hiring or subcontracting signature <br /> certifies the folo'A: .1011 that in the performance of the w4kiarmi is issued, I shall employ persons subject t workman's compenss- <br /> tion laws aliforn <br /> The t hwst ca r I raquir inspbctions. Complete d11 <br /> e sr e.sig Date:JZ]i �. FORUSE ONL I <br /> 4 , <br /> Application Accepted by _ _std--� - ats roe P? t—A i <br /> � - I <br /> Pit or Grout Inspection by Date Final Inspection bv Date <br /> �� <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, Box 2009, Stkn, CA 95201 <br /> IEEE AMOUNT DUE AMOUNT REMITTED Cx -SKEIVED BY E PERMIT'NO. <br /> . EH 13-24(REV.i i n a) <br /> EH 14.20 <br />