Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION j <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 i <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERF T E%PIRES 1 YEAR FROM DATE S <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 5k9 and and the Rules and Regulations of San s <br /> Joaquin County Public Health Services. <br /> Job Address City Lot Size/Acreage <br /> 931-IVS0 I <br /> ✓ <br /> Owner's Name Address ✓ Phone�{f <br /> Address�26 S _ License No. Phone <br /> Contractor t <br /> TYPCOF WELL/PUMP: NEW WELL C1WELL REPLACEMENT f] DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION © SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER L1 S DISPOSAL FLD. - " ' PROP. LINE <br /> f FOUNDATION AGRICULTL E ELL. LOTHER WELL PITS/SU <br /> WMPS .__ <br /> r fa <br /> INTENDED USE TYPE OF WELL PROBLEM AREA C RUCTION SPECIFICATIONS " <br /> f 1 Industrial ❑ Open Bottom a ❑ Manteca Dia. of Well Excavation Dia. of Wall..Casing <br /> tf <br /> Cl^Domestic/Private L1 Gravel Pack L7 Tracy Type of CCasing_ —Specifications <br /> I'.I Public s n Other, n Delta Depth of Grout Seal Type of Grout- { <br /> I I Irrigation { "_ _�Approx. Depth ?I I Eastern Surface Seitl Installed by <br /> Repair:Work Done U Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑. Well Diameter Sealing>l{sterial & Depth . <br /> f' f Depth- Mller Material Depth. `. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION Il DESTRUCTION I i lNo septic system permitted if public sewer is �7 <br /> 1available within 200 feet.} <br /> � <br /> r t v 1. z <br /> Installation will terve: Residence_ Commrcial_ Other <br /> _ umbar of living units. Number of bedrooms-__ <br /> ff f <br /> Character of snit to.*depth of 3 feet: -` to/table depth <br /> SEPTIC TANK -❑ Type/Mfg P • <br /> omp�artments <br /> - � s l <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> k Distance to nearest: Wi Foundation Property line <br /> y � . <br /> LEACHING LINE ❑ No. b Length of lines t a. Tg4al <br /> length/size <br /> FILTER BED ❑ Distance to nearest. Well YJ r- Foundation_ L�/{�� Property Line j <br /> SE£PA(3E•PITS.-.-.—11—. .Depth�IeE <br /> � <br /> SUMPS r Ll Distance to rest: Well A[L ►' Foundation fJ Property Line r � <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 /> rules and regulations of the San Joaquin County i. <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 i ecoms subject to workman's compensation lawsof California." Contractor's hiring or sub-contracting signature s <br /> certifies the following: "I certify that in the performincs 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 t call forwired t pections. Complete drawing on reverse side. <br /> Signed Title: f Date: <br /> E FOR DEPARTMENT USE ONLY <br /> r �T - ��^ �Z Area p L� <br /> Application Accepted by Date <br />` Pk ut or GroInspection by Data Final Inspection by Date <br /> E 'r <br /> Additional Comments: t <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P-O Box 2009, Stkn, CA 95201 <br /> ? FEE AMOUNT DUE AMOUNT REMtTTEO CK 8 CASH RECEIVED BY DATE PERMI7'N0. <br /> INFO <br /> I r- J� <br /> I EH 13-24(REV.t N 5) e O� �+ w 43 <br /> EH t1.7a <br />