Laserfiche WebLink
APPLICATION FOR PERMIT <br /> Y 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 EXPIRESYEAR FROM DATE- ISSUED <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 1962 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> ob Address <br /> ,'s J <br /> 45 / rt e� /' City �+I p/ f,/� <br /> Lot Sine/Acreage <br /> gl ,�f( ,�r-y� y1� <br /> -,.Owner's Name <br /> G } "r Address Phoney <br /> �ontractor if4 Address '� Of License No. Phone <br /> i"YPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F1 DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well n <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I-] Industrial ❑ Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing <br /> n Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'I Public 1:1 Other fl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigalion _Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done L7 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Weft Diameter Sealing Material i Depth <br /> Depth 7111er Material i Depth <br /> HYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is <br /> /! available within 200 feet.l <br /> Installation will serve: Residence— Commercial_,� Other <br /> Number of living units: Number of bedrooms <br /> Character of soll to a depth of 3 feet: l C Water table depth <br /> I SEPTIC TANK. ❑ Type/Mfg tt C Capacity_ O No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to clearest: well Foundation Property Line <br /> LEACHING LINE LAS No. a Length of lines r0 T tat length/size �_0 <br /> FILTER BED 0 Distance to nearest: Well 1(749Foundation s Property Line <br /> f ' <br /> SEEPAGE PITS ;I I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ + <br /> I hereby cenify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rulas 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 /> emptay any parson in such man r as to become subject to workman's compensation laws of Calilornia." Contractor's hiring or sub-contracting signature <br /> cenifies theJotlbwin'#• "I cenify hat in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion 4 awE of Califar <br /> The App`HGm cal or i t #od ins pectiops. Complete drawing on reverse side. <br /> Signpd.XTitle: Data: <br /> ! 1 " <br /> Ui <br /> FOR DEPARTMENT USE ONLY <br /> i f-7 <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final inspection by Data <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, P O Box 2009, Stkn, CA 95201 <br /> mlltl-t-x) <br /> AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERmrr-NO.` <br /> CASH <br /> . EFS t}34 IREV.t nSI f . �-1 ?_ 9l.•� 3 ' <br /> EH 1•-M <br />