Laserfiche WebLink
,f <br /> APPLICATION FOR PERMIT <br /> 1 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQIIIN11 PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT ESPIRES l YEAR FROM DATRISSUED <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 1s made in compliance frith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin Coun Public Health Services. <br /> Job Address _ ��t �� , City Lot Size/Acreage <br /> IJAD <br /> er's Name t Address --� Phone 3 J F <br /> Ak��re_W Zb - No Phone 3 t U <br /> TYPE OF WELLIPUMP; NEW WELL W WELL REPLACEMENT��.. DESTRUCTION Cl Out of Service Yell ❑ <br /> jl PUMP INSTALLATION EI SYSTEM REPAIR �f" OTHER C) Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> 11 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE ; TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C7 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private V ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> 11 Public Cl Other Cl Delta Depth of Grout Seal Type of Grout i <br /> kW <br /> ation —.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done L3Type of Pump H.P. State Work Don <br /> Well Destruction ❑ I'Well Diameter Sealing Material i Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> ,I `__ _ _r, available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units:U Number of bedrooms — <br /> Charscter of soil to a depth of$feet: Water table depthr <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments 1 <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> II Distance to nearest: Well .Foundation Property Line <br /> LEACHING LINE 0 No. 8 Length of lines R Total length/size k <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS III Depth Size Number <br /> SUMPS Lt 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-dorso in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the Son Joaquin:County <br /> 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 became subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature \ <br /> certifies the following: ^I a that in tha performance of the work for which this permit is Issued,I shall employ persons subject to workman's mpensa a{�J <br /> tion laws of all Ia.,. " a5L` <br /> Thea call f NI r ins ctions. Complete drawingCnr!Ayefside. <br /> Sig Title. Date: <br /> e - r -FOR DEPARTMENT USE ONLY <br /> Application Accepted by W✓ __ Date - __ ��-�`9- - - <br /> � Area <br /> Pit or Grout inspection by, Date Final Inspection by Data R f5Z <br /> Additional Comments: i1 <br /> Applicant —Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health_Permit/Services <br /> jj 445 N San Joaquin, P.O Box 2009, Stkn, CA 95201FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK CASH r RECEIVED BY DATE PERM1I 5�1 <br /> + EN13-24 IMEV.1 $15) P(L x �j` <br /> EH 14.20 �r Q • 1�5' c <br /> t <br />