Laserfiche WebLink
t <br /> { APPLICATION FOR'PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I ENVIRONMENTAL HEALTH DIVISION <br /> �P O BOX 2009, STOCKTON, CA 95201 <br /> LUIT (209) 468-3447 <br /> EXPIRES 1 YEAR PROM DATE ISUUED <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 coatpliancel4ith San Joaquin County Ordinance No. 5h9 and 1862 and the Rules and Regulations of San <br /> J uta County Publ <br /> ic Health Services./op <br /> ss , <br /> Job AddraV �`�) ' City C Q, Lot Size/Acreage <br /> 1 <br /> Owner's Name Address __- --_-._ Phone <br /> antractor � � �! Address � � I License No,% „�4horte �J <br /> TYPE OF WELL/PUMP: NEW WELL 1:1WELL REPLACEMENT C7 DESTRUCTION C� Out of Service Well ❑ <br /> � . <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <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 SPECIFICAT <br /> 111 Industrial ❑ Open Bottom El Manteca Die. of avation Dia. of Well Casing <br /> CJ Domestic/Private 0 Gravel Pack;., ❑ Tracy ype of Casing_ Specifications <br /> M Public Cl Other a Depth of Grout Seal Type of Grout <br /> M Irrivalion .Approx y fl Eastern Surlaca Seat Installed by <br /> Repair Work pone U T Pump H P. Stats Work pone_ Ji <br /> Well Destruc ' n Well Diameter f Sealing Material i Depth <br /> Depth I Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION Cl- DESTRUCTION RNo septic system permitted if public sewer is <br /> I available within 200 feet.) v <br /> installation will serve: Residence r Commercial T Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: t). <br /> Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg I - Capacity No. Compartments <br /> PKG, TREATMENT PLT. 0 Method of Di <br /> < spoaa) <br /> Distance to nearest: 'Wail Foundation Property Line <br /> k LEACHING LINE 0 No. S Length'of lines Total length/size <br /> j FILTER BED ❑ Distance to nearest: Well *Foundation- Property Line <br /> F SEEPAGE PITS 11 Depth ) Size Number i <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ - 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 4 r_ -- <br /> r 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 /> 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 taws of California." T <br /> The applicant must call for all required ins ctions, Complete drawing on reverse side' f <br /> Signed r Title: Date: <br /> 1 <br /> .F <br /> TMENT USE ONLY t <br /> }pplication Accepted byDate i 1 S ^ Area <br /> r <br /> 'It or Grout Inspection by Date Final Inspection by �'�--� pats O <br /> dditional Comments: <br /> Lr <br /> rplicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES — <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, p 0 BOX 2008, STOCKTON, CA 85201 E <br /> E � <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO CASH RECEIVED BY DATE PERMIT'NO. <br /> IREV.IIns) 7 QC7 1 <br /> r . <br />