Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCSTON, CA 95201 <br /> (209) 4683447 <br /> YEA R 9RQM-DATE ISSUER <br /> (Complete in Triplicate) <br /> Application is hereby made.to Ban Joaquin County for a permit to construct and/or install the work herein described. This <br /> applicatiou is made in cerWliance with San.Joaquin County Ordinance No. 549 and.1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> f <br /> Job Address City Lot Sfze/Acreage <br /> f /1/J�f[} ,PrLF✓I�CCiLL Address Phone <br /> Owner's Name. <br /> Contractor <br /> } Address-10-6 Phon <br /> 1 <br /> TYPE OF WELLIPUMP:, NEW WELL WELL REPLACEMENT L.1 DESTRUCTION ❑ Out of Service Well Cl <br /> PUMP INSTALLATION C] <br /> SYSTEM REPAIR ❑ OTHER ❑ Monitoring well C7 <br /> DISTANCE TO-NEAREST: SEPTIC TANK SEWER LINES ) DISPOSAL FLD. PROP. LINE/ <br /> FOUNDATION AGRICULTURE WELL := OTHER WELL PITS/SUMPS <br /> 1 INTENDED USE s TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ag Mrit <br /> fl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Exca anion Dia, of Well Casing <br /> U Domestic/Private )Z Gravel Pack - Tracy Typa of Casingf Specifications <br /> A Public �afL�1 Other ❑ Delta Depth of Grout Seal <br /> Type of Grout <br /> �`,�i,lrripation �, Approx. Depth ❑ Eastern Surface Seat Installed by r <br /> Repair Work Done U Type of Pump H,P, State Work Done v\ <br /> Well Destruction ❑ Well Diameter sealing Material 6 Depth <br /> Depth r Filler Material i Depth <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION 0 DESTRUCTION El (No septic system permitted if public sewer m <br /> {. available within 200 lost.1 <br /> installation will serve: Residence J Commercial ___ . Other <br /> Number of living units. Number of bedrooms . <br /> Character of soil to a depth of 3 feet-.1, rY Water table depth <br /> SEPTIC TANK. ❑ Type/Mfp Capacity- No. Compartments <br /> PKG. TREATMENT PLT, 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> !`L <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: WellFoundation Property Line <br /> f <br /> I SEEPAGE PITS I I Depth Site Number <br /> SUMPS LI -Distance to nearest: Well Foundation ,Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby canify that I have prepared this application and that the work will be done in accordance 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 laws of Calilornia."C6ntractor'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 empioy persons subject to workman's compensa- <br /> tion laws of California." <br /> i The ap nt all r ail a uired ' spections. Complete drawing on r to side: f <br /> //� /L! ,�'l�L Date: <br /> Signed' & Title:� ,.,( <br /> EPARTMENT USE ONLY <br /> Application Accepted by Date © Area____�_ <br /> 4 All <br /> Pit or Grout Inspection by Date Final Inspection by Date q q <br /> t 11 <br /> Additional Comments <br /> G,e-a-2t v ,� <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 BOX 2000, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> . EH 13.24 IrrEY.1 i n sf `�` V t�Q �" —'s- - <br /> EH:4.26 <br />