Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1 <br /> ENVIRONNMNTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PERMIT EMI99S 1--YEAR FROM DATE ISSUE <br /> (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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. 9l <br /> Job Address ._ yfil �`/ �/C; Z 91Q City Lot Size/Acreage <br /> Owner's Name <br /> Address Phone <br /> _ �v u � <br /> Contractor <br /> �/[_ /`� S ddress License No. 4 � Phone <br /> h WELL WELL REPLACEMENT C7 DESTRUCTION ❑ Out of Service Well UTYPE OF WELL/PUMP: NE <br /> -. Monitori�8 Well <br /> PUMP INSTALLATiOt SYSTEM REPAIR ❑ � - OTHER ❑ / C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK ZM SEWER LINES --"'� DISPOSAL FLD.-- PROP. LINE�d <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ZC <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI914S f <br /> M Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _'-_ Dia. of Well Casing <br /> Domestic/Private Gravel Pack 11 Tracy Type of Casing, ;:I <br /> '' Specifications ; <br /> M Public I�l nOther D Delta Depth of Grout Seal Type of Gro- <br /> Ci Imgation p2Approx.'Depth ❑ stern Sy ce Soul installed by <br /> Repair Work Done 0 Type of Pump M.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing haterial. & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION D REPAIR/ADDITION Ll DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feel.) C <br /> Installation will serve: Residence.._- 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 Capacity No. Compartments <br /> PKG. TREATMENT PLT, ❑ Method- <br /> of Disposal <br /> f Distance to nearest: Well Foundation Property Line <br /> { <br /> LEACHING LINE D No. & Length of lines Total length/size <br /> FILTER BED 173 Distance to nearest: Well Foundation Property Line <br /> t <br /> SEEPAGE PITS I I Depth Size 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 viill-be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the Sen Joaquin County <br /> Home owner or licensed agent's signature certifies the'following; "I certify that in the performance Bf 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 taws of California." Contractor's hiring or 4b-contracting signature <br /> certifies the following: "I certify that in thepoi1ofmance of the work for which this permit is issued, I shall employ persons subject to workman's compensa, <br /> tion laws of Cal' la." :- <br /> The appl' t u c I to s. Complete drawing on rs er Ode <br /> Signed Title: r Date: <br /> 9 <br /> f i <br /> l � <br /> ORM=MENTONtYApplication Accepted b, Data �— L -- Area <br /> Pit or Grout Inspection by D Data aD � Final Inspection by Date <br /> , <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> TM 445 N,SAN JOAQUIN, P 0 BOX 2009', STOCKTON, CA 85201 <br /> a � <br /> FEE AMOUNT DUE AMOUNT AEMITTED CASH RECEIVED 9Y DATE PERMIT'NO. <br /> ti <br /> INFO <br /> i <br /> . Cl <br /> EEH <br /> H 13-24INEV.11 AS) 0� ^�^'-�b 7 <br /> u•Ia <br />