Laserfiche WebLink
APPLICATION FOR PERM T {U-�J <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PEMIT EXPIRES 1_YTAR FROM PMTS ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made,to Sap 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. 5119 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address Y/no /h41City �� flet-Sl-ie/AcreageIW�& _� f <br /> Owner's NsriG '` r, - Via' Phone <br /> Con C Or G License N Phone a� <br /> TYPE OF WELL/PUMP. NEW WEL WELL;REPLACEME ❑ DESTRUCTIO Out of Service Well L1 <br /> PUMP INSTALLATION SYSTEM REPAIR❑� OTHER'❑ Monitoring Well C� <br /> DISTANCE TO NEAREST: SEPTIC TANK �P1 r SEWER LfNES DISPOSAL FMD. - PROP. UNE ' <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f <br /> ' Ln Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavat' Dia. of Well Casing <br /> Domestic/P►ivate IGravef Pack ❑ Tracy Type of Casing Specifications <br /> OOWPublic i, Other ❑ Delta �D.epth pf G o_ut Seal E_fQ_ _ Type Grou r <br /> CI Irrigation Approx. Depth �❑ Eastern Surface Seuf Installed by tS !I 1 h <br /> Repair Work Done U Type of Pump H.P. State Work Done�. <br /> Wall Destruction ❑ Well Diameter sealing Material i Depth <br /> Depth <br /> Filler Material i Depth' In <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION M DESTRUCTION CI (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feat: Water table depth <br /> SEPTIC TANK ❑ Tyne/Mfg Capacity No.'Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> i <br /> t LEACHING LINE Cl No. & Length of lines Total langth/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS LI Distance to nearest: 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 <br /> I. rules 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 whicWthis permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of Calilornia." Contractor's hiring or sub-contracting signature <br /> Certifies the following: "!certify that in th®performance of the workforwhich this..permit is,issued, I shill sTpioy-par�ans.subiect.to_workman's compensa- <br /> tlon`Iawi'of"Catifo►rile." = _ <br /> The applicant must 41 for al.required in ctions. Complete drawing on reverse side - <br /> .J r' <br /> ` <br /> Signed itle:-_�/i - W - <br /> �� - - — <br /> - -- -Dat:��11, <br /> 77 TMENT USE ONLY <br /> Application Accepted by R Date L <br /> Area <br /> Pit or Grout Ina ` '2i l a <br /> pection y b ``Date F' 'I:_Inspectio/n by �'__�/�s�S,�w� Date 3 z? <br /> Additional Comments: <br /> Applicant - Returo all copies to: SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 H SAN JOAQUIN, P O BOX 2009, STOCKTON, CR 95201 <br /> FEE INFO AMOUNT DUE AMOUNT tiEMlT7tSD CASH RECEIVED BY DATE PERMIT NO. <br /> . E�eua.tnev.,�»sr -rte <br /> 6y -31 <br /> CHI <br /> (� <br /> CHI 74-A ` V 9 0 P <br />