Laserfiche WebLink
Y APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> r ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3+ 4-T..3t/,;'-0 <br /> P MIT .EXPIRES 1 YEAR-_VRQM DATE ISS= <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 Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address W`L Lo,,-,t iWr ``"`-' City '57f Ock�i 072Lot Size/Acreage <br /> Owner's Name �" 1�� I"` Address `" / / G Phone3 / &lDL�� <br /> Contractor UJ H65 Address License No. Mt, Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Out of Service Nell <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS j <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> M Public f"11 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> M Irrigation .Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION G (No 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 soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> i <br /> I <br /> LEACHING LINE ❑ No. & Length of limes Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sue Number <br /> SUMPS LI Distance to nearest; WeII Foundation Property Line <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, state laws, and <br /> rules and regulations of the Sari 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 California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I Certify that in the riormanca of the work for which this permit is issued, !ahail employ persons subject to workman's compenaa• i <br /> lion laws of��j <br /> a." <br /> The applicanr all requir nspgctions. Complete drawing on reverse side. <br /> Signed Title: A-•tAA-L-.A Date: i <br /> R DEPARTMENT USE ONLY c� <br /> Application Accepted by 1AA Date „ Area <br /> Pit or Grout Inspection by Date 3 A7 CL? Final Inspection by y. �•. ..a__�_ aJF� Date ,i _ <br /> Additional Comments: i5 <br /> r <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 /> INFO AMOUNT DUE AMOUNT nEWTTED CASH RECEIVED BY DrtAfT_E PEAMIT'NO. <br /> . EHq24IREV.iiAsiQr <br /> EH 114-A I� <br /> I <br />