Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISIONf , <br /> P 0 BOX 2009, STOCKTON, CA 95201 . p <br /> (209) 468-3447 SEP 2 4 lgpo ` <br /> - 'J'IJlR(�� <br /> (Complete in TriplicateimE ) PERMIT c2jj�C <br /> EIVcAL ICES; <br /> es e(E <br /> vork <br /> Application is hereby �e.to San tialthuSanin CJoaquipocounr a tyrordinancemit to nNo. 549 and A62struct and/or aa d the tall eRules andRegulationsSanThis � <br /> application is made in coup ; <br /> Joaquin County Public Health Services. <br /> Lot Size/Acreage <br /> ty <br /> Job Address E R a 9 <br /> Phone I <br /> ddress =_ <br /> Owner's Nam <br /> Cor drWell <br /> Ocense No. �•Phone ���� <br /> NEW WE ❑ WELL REPLACEMENT _ DESTRUCTION L7 Out of Service Well ❑ <br /> TYPE OF WELLlPUMP: OTHER ❑ Monitoring Ll <br /> PUMP INSTALLATI SYSTEM REPAIR <br /> LINE <br /> EWER S :— DISPOSAL FLD. PROP. LINE Y <br /> DISTANCE TO NEAREST: SEPTIC TAN!(' ' 07iiER WELL PITS/SUMPS <br /> FOUNDATION �.� �— AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL ' 9PR09L� EM AREA CONSTRUCTION SPECIFICATIONS Dia. of Welt Casing <br /> ❑ Open Bottom ❑ Manteca Die. of Well Excavation <br /> D Industrial Specifications i <br /> Type of Casing <br /> mastic/Private ❑ Gravel Pack ❑ Tracy Depth of Grout Seel Type of Grout I <br /> M Public I'1 Other ❑ Delta + <br /> CJ tnigation �.Approx. De E tem Sur]�ce Sau! Instaildd by ` <br /> H.P. �l ,aVk D e <br /> Repair Work Done �e Type of Pumps f Sealing Material i Depth Gi.�71 <br /> Well Destruction O Well Diameter <br /> 4 Depth <br /> Depth *—�""°`Fi1'les Material ti <br /> TYPE QF SEPTIC WORK: NEW INSTALLATION I REPAIRlADDITIQN CI DES7RUC710N G available etlw thin 200 Ieetltled if public sower is <br /> I li <br /> Installation will serve: Residence r' Commercial Other <br /> Number of living units: Number of bedrooms---. r <br /> Water table depth <br /> Character of soil to ■ depth of 3 feet: <br /> Capacity— No. Compartments <br /> SEPTIC TANK © TypelMfg tulatho�d of Disposal <br /> PKG. TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: Well 4 Foundation'— <br /> Total length/size <br /> LEACHING LINE D No. & Length of lines property Line <br /> FILTER BER ❑ Distance 1 o nearest: Well Foundation <br /> ,.I <br /> Number <br /> SEEPAGE PITS I I Depth Size Property Line <br /> SUMPS Ll Distance,to nearest: Well Foundation�--- <br /> DISPOSAL PONDS ❑ <br /> T I hereby certify iharl have prepared this application and-that-the work'will be done in iccordance'with'San Joaquin coumy brd+nancati,stale laws, ander <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 California." Contractor's hiring or sub contracting signature <br /> eerploy the following;in u certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa• <br /> f tion laws of California." <br /> The applicant Crall for a ,re ired ins ctlops, Complete drawing on r rse si <br /> t Titl Date: (� <br /> Signed,3.r�� —�— <br /> a FOR EPARTMENT USE ONL . 7 2 <br /> f 7 <br /> Date _ Area <br /> Application Accepted byDatF 3~���1 <br /> Final Inspection b t <br /> Pit or Grout Inspection by Date -- _ <br /> Additional Comments: <br /> Applicant Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES t� <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES _ r1TJS`y <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 85201 <br /> FEE CK RECEIVED Sy DATE PERM17 NO. <br /> INFO AMOUNT DUE; AMOUNT REMITTED CASH cr d <br /> . 19 <br /> EH 0.24 tREV.+'AS) <br /> Eh:416 <br />