Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL UIN, HP <br /> ALTH DIVISION <br /> 445 NSAN E (209)468-3420 �` <br /> P 0 BOX 2009, STOCKTON, CA 95201 Ff�yp� N 410; �d'1 <br /> PERMIT EXPIRES 1. YEAR FROM DATE S N 'S'RQ�/ 9�`4 <br /> (Complete in Triplicate) �i<yT � /N�0`9� <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein�li" fn' � . This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Hegulitlonne"of San <br /> Joaquin County Public Health Services. rS1;J , <br /> Job Address k &2_- City A Lot Size/Acreage <br /> ­ ff -Owner's Name Address lC I ly�- - __ Phone <br /> Contractor Address License No.-wt-Phone <br /> TYPE Of WELL/PUMP: I NEW WELL ❑ , WELL REPLACEMENT 177 1 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR � OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I-] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> i l Public i F1 Other ❑ Delta Depth of Grout Seal Pe of Grout <br /> t I Irrigation -.Approx. Depth I I Eastern Surface Sal Installed by <br /> Repair Work Done Ll Type of Pump + H.P. _ f State Work Done KAAJArA <br /> 1 Watt Destruction ❑ Wall-Diameter f t Sealing Material i Depth <br /> i Depth !,� �, )tiller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is <br /> t t I I - i. available within 200 feet.) <br /> Installation will ssrra: Aesidence_ Commercial r._,. Other <br /> Number of living units: Number of bedrooms I i <br /> Character of soli to a depth of 3 feet: i Water table depth <br /> SEPTIC TANK. d� Type/Mf+g_& -- - Capacity No. Compartments <br /> PKG. TREATMENT PLT."❑ r t Method of Disposal <br /> Distance to nearest: well Foundation Property Line <br /> S <br /> LEACHING LINE 1 ❑ No.4 Length of lines --- Total length/size <br /> FILTER BED 't Cl Distinee.to-nearest: Well Foundation Property Line <br /> i- tel• .�� � <br /> SEEPAGE PITS l d I' Depth ""' �'' Size Number <br /> SUMPS # Ul.r Distance to nearest: Well Foundatidn Property Line <br /> DISPOSAL PONDS ❑ i t <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, slate laws, and <br /> rules and regulations of the Sen Joaquin County <br /> Home owner or licensed agent's-signature-csrtifies-the-following:--'1-certify-that-in the performance of the work for which this permit is issued, I shall not <br /> r employ any psreo such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature <br /> certifies the f', . "1 certify that in the performance of the work for which this permit is issued,I shall employ personi subject to workman's compenes- <br /> tion laws of <br /> The apptican call for all requir apactions. mplate drawing on r ver a ide. i <br /> t <br /> Signed Title: Date: <br /> s FO EPAStONLY l <br /> Application Accepted by Dats Area <br /> Pit or Grant Inspectbn by s Date Final Inspection b <br /> F <br /> Additional Comments? <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> { Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> t <br /> FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY ATE PERMIT'NO. <br /> INFO <br /> 01 <br /> . EH 13-21(REV.1in5)T>� r <br /> EH 14.20 <br />