Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> YEAR, <br /> (Complete in Triplicate) <br /> Application is hereby made to San!Joequin 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 /> O �e� 1 City Lot Size/Acreage <br /> Job Address q <br /> _,,, - _ - �. -- --•-.... �- --• Pho <br /> _Owner's Name ddress <br /> Address x ices <br /> �� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION LiVut or ervice Well Ll <br /> Monitoring well [7 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD• PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PtTSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f-] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> Specifications <br /> U DomesticlPrivate ❑-Gravel Pack ❑ Tracy. Type of-Casing- - Type of Grout <br /> -Publie L T Oiher�•---��--� ---❑ Delta Depth of Grout Seal <br /> I 0 Ifngation ^.Approx. Depth ❑ Eastern Surface Seal Installed by C <br /> H.P. State Work Done <br /> Repair Work Done {J Type of Pump <br /> Sealing Material,& Depth, <br /> Well Destruction 0 Well Diameter <br /> Depth Filler !late iti401111, - i Depth stern <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIO EPAIR1AROiTION DESTRUCTION M (No septic chin 2t)O free'it`ed if public sewer is <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units. _4(-- umber 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 I ' i Method of Disposal <br /> F , <br /> Distance to nearest: Well Foundation •.- Property Line <br /> LEACHING LINE X No. 5 Length of lines -Boom' Total)ength/si:e <br /> FILTER BED [] Distance to nearest: Weltoundation Property Line <br /> SEEPAGE PITS JI Depth Size _r Number <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ + 3�i �` <br /> I hereby certify that I have prepared this application and that the work will be done in accordance withSanJoaquin county ordinances, state laws, and <br /> rules and regulations of the Sen 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 subcontracting signature <br /> ' certifies 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 /> e applicen sl c I for all required i Uions. Complete drawing o verso side: <br /> . <br /> Signed Title: -- Data. - <br /> t _ <br /> r R DEPART. NT„UAE ONLY. _ - <br /> i. - LVAD _ <br /> Dale 3 Area - <br /> Application Accepted byLIA .. . <br /> gyp, ♦ ' -X �Z / <br /> Pit or Grout Inspection by Date Final'Inspection bData <br /> y / <br /> Additional Comments: k <br /> t Y 5 <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �. T <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 95201 <br /> CK I <br /> FEE AMOUNT DU£ OUNT REMITTED : CASH RECEIVED BY DATE „ PERMIT'NO. <br /> INFO ,.�—�`� �^� �+.,I�'7 / p��}'���`/'��^� <br /> . EH U-34 WEV.1 r n 5) CAI 11.� 1 � C�� <br /> EH:�•?6 _ v _ <br />