Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, `CA. 95201 <br /> (209) 468-3447 <br /> PENIT EXPIRES 1 YEAR kROW DATE- ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in eomliance vith San"Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Jab Address City M`� Lot Size/Acreage <br /> Owner's NameIf' 1r____�G e— Address C Phone <br /> Contractor j. L ,Ittrr. Address P0, 6.r License No.. z.r58'a� Phone _u <br /> TYPE OF WELL/PUMP: _ NEW_WELL ❑ WELL REPLACEMENT C7 DESTRUCTION ❑ Out of Service Well C) <br /> PUMP INSTALLATION ❑ ti- SYSTEM REPAIR ❑ OTHER ❑ Monitoring-Well [7 <br /> DISTANCE TO NEAREST: SEPTIC TANK { SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE, -T P:9_OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , <br /> n industrial ❑ Open Bottom a ❑ Manteca Dia. of Well Excavation Diiii of Well Casing <br /> U Domestic IPrivate" Cl Gravei Pack 0 Tracy Type of Casing Specifications <br /> Z) P0011ic Ia Other p Delta Depth of Grout Seal Type of Grout <br /> M Irrigation Apprax, Depth " ❑ Eastern Surface Semi Instalied by <br /> Repair•Work Done 0 Type of Pump H.P. State Work Dona <br /> Well Dloatruction ❑ Welt Diameter Sealing Material i Depth = r <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTA_LLAT10N REPAIR/ADDITION M DESTRUCTION G INwseptic system permitted if public sewer is <br /> available vrikhin;200'feet.l <br /> Installation will serve: ResidenceI! Commercial^ Other <br /> j <br /> Nurri6ir of living units: } Number of aedroorYts <br /> .ZCharacter of coil to a.depltt of 3 feet:i... t`Anl�'} Wataia$feepth <br /> TIC-TANK Type/Mfi AGe 0 SOL Capacity.1 pW No. Compartments t <br /> PKG. TREI. <br /> ATMENT PLT, Cl / v Method of Disposal <br /> Distance to nearest: Well F61uridiiioiiProperty Line <br /> 1 '- <br /> LEACHING LINE Pr-No. & Lengih•of lines Tolil length/size f5 <br /> FILTER BED a n Distance to nearest:et: Well�_ Foundation ( Property Line,Sn <br /> SEEPAGE PITS II Deptti'1 Suft { Number i <br /> SUMPS Ll Distance to n; res[w Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 Y <br /> rules and regulations of the Sen Joaquin County, t k�' <br /> Home owner or ficansed ageni's signature coMi(*i1,ttHs following:,"I certify that in the performance-of the work-for which this.permil.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 /> candies 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 applicant must call for all r9quired inspections, Complete drawing on reverse side. <br /> Signed X " i = } . Title:^- d�o s4`� _ Dale: <br /> FOR DEPART ENT U E ONLY , !+ <br /> Application Accepted by i d Date r _a <br /> Pit or Groul Inspection by Date `mss Final Inspection by Dets <br /> Additional Comments: r , <br /> Applicant — Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 448 N SAN JOAQUIN, P o BOX 2009, STOCKTON, CA 96201- <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIVNO. <br /> .,EH 13.24 UrEV.riMS "A h X <br /> Q <br /> . d <br />