Laserfiche WebLink
it <br /> I <br /> APPLICATION FOR PERMIT <br /> F 1i <br /> , SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> �M ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTONT, CA 95201 <br /> k I (209) 468-3447 <br /> EMIT EXPIRES 1 YEAR rROM PATE- ISSUED <br /> i� (Complete in Triplicate) <br /> i' <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application ie made in ccupliance vithl$an Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services.. . <br /> ! <br /> Job Address .�Gpti�J 1 1" City Lot Size/Acreage <br /> r ' �' <br /> Owner's Name � S r/�' ��d-/ .S 01 _ Address •�� �-d Phone <br /> Ii <br /> rContractor A Address License No. Phone <br /> TYPE OF WELL/PUMP: ,NEW WELL C1 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP iNSTALLATIOf�.>�'^ SYSTEM REPAIR ❑ OTHER D Monitoring Well <br /> F DISTANCE TO NEAREST: SEPTIC TANK IM Y SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL _OTHER WELL PITS/SUMPS <br /> i <br /> INTENDED USE TYPE OF.WELL I PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial 0 Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing <br /> _*omestic/Private Gravel Pack 0 Tracy Type of Casing Specifications <br /> M Public I-1 Other 0 Delta Depth of Grout Seal Type of Grout <br /> 0 lrrigation _.Appro�, Dth ❑.Eastern Surface Seal Installed by <br /> Repair Work Done LJ Type of Pump H.P, ` State Work Done_ <br /> Well Destruction 0 Well Diameter Sealing Material i Depth d <br /> Depth :[ I� Filler.Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIWADDITION 0 DESTRUCTION CI (No septic system permitted if ptiblic sewer is N) <br /> �I available within`200 fest.f <br /> Installation will serve: Residence r 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 IM Capacity No. Compartments ry <br /> f PKG. TREATMENT PLT.C1 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE C1 No. &.Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> A IM <br /> SEEPAGE PITS 11 Depth ' i Site Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 IN <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 /> I Home Owner or licensed agent's signal6re 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 performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." f iI <br /> { The applicant mut I for all required iinspectiono, Complete drawing on reverse side. <br /> Signed Title: rg aj yt (I Date: <br /> FOR DEPAR NT USE ONLY <br /> Application Accepted by Date � Area �( <br /> i <br /> Pit or Grout Inspection by Date Final Inspection by Data <br /> Additional Comments: Ji _ <br /> Applicant - Return all copies to: SAN IJOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> } 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON. CA 95201 <br /> CK 07 <br /> INFO <br /> EEE AMOUNT DUE AIMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NQ. <br /> . fM 13•2I(REV.i i 5t 3� 111^ <br /> """26 <br /> �. R P <br />