Laserfiche WebLink
APPLICATION FOR PERMIT �4 J �r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447PFAU <br /> p�14 <br /> I (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 CoMlia.nce:with San Joaquin County Ordinance No. 549 and 1862 and the Rules rind Regulations of Ban <br /> Joaquin County Public Health Services. <br /> lob Address ® O 1�� City <br /> Lot Size/Acreage <br /> I t , <br /> Owner's Name <br /> t4 / U & o? Address -4/Q 0 AW,� r/��%Cj Phone 1 <br /> (� <br /> ontractor jf)/l1� Address S License No. Phone <br /> TY E Of WELL/PUMP: NEW WELL ❑ WELL_AEPLACEMENT-n . ., DESTRUCTION C1 Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR C7 OTHER ❑ Monitoring Well C7 <br /> i DISTANCE-TO NEAREST: SEPTIC TANK SEWER LINES -,DISPOSAL FLD� - PROP. LINE <br /> } FOUNDATION AGRICULTURE WELL L� OTHER WELL SPITS/SUMPS <br /> .. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ClManteca Dia. of Well Excavation" Dia-of Well Casing <br /> Type U Domestic/Private Cl Gravel Pack ❑ Tracy T Yp of Casing Specifications <br /> M Public fa°Other ❑ Delta Depth of Grout Seal Type of Grout <br /> CJ Irrigation Approx.'Depth ❑ Eastern Surface Seal Installed by <br /> Repair-Wolk Done LJ 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 REPAIRIAODITION 0 DESTRUCTION (No septic system permitted if public sewer is <br /> f vailable within 200 feet.l, <br /> Installation will serve:. Residence Commercial_ Other <br /> I` Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK N © Type/Mfg Capacity No. Compartments <br /> a <br /> PK G. TREATMENT PLT, C1 - Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> - [ r <br /> wor LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED 1:1 Distance to nearest: Well Foundation _ YProperl Line <br /> h__ __.__ <br /> 1 <br /> ." SEEPAGE PITS I I Depth f Sire Number -A <br /> SUMPS Ll Distance to nearest: Well Foundation Property Linn <br /> S 0 <br /> DISPOSAL POND <br /> i - <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 San Joaquin; County <br /> rtify that in the pert mance rn the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I ce <br /> employ any person in such manner as tti 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 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 /> The applies tet l fo r quir5d inspections. Complete drawing on reverse side. Q <br /> Signed <br /> Title: , _._ Data: <br /> �{ FO DEPARTMENT USE ONLY ' <br /> I Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by -cam. Data 4 `l0 <br /> Additional Comments: <br /> 't <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 1 ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 n <br /> f INFE AMOUNT ()UE,i AMOUNT REMITTED CASHRECEIVEO BY / DATE PERM17'NO. <br /> . EH 1 .24 IREV,I/N 51 <br /> EH'4-M <br /> L ' <br />