Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> %,--(209) 468- 3yp_6 o `tee V" <br /> xT (Complete Triplicate) <br /> in �ROMD Ig�� <br /> P <br /> 57 <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herell R. <br /> ta�rSybed. T}li"e <br /> application County <br /> [Wade In Health <br /> services. <br /> with Ban Joaquin County Ordinance No. 51+9 and 1862 and the Rules and ReM �ip� of Ban <br /> Joaquin County Atb11c Health Services. <br /> Job Address City Lot Size/Acreage ` X <br /> eelf <br /> Owners Name Address <br /> __. � Phone <br /> Conlractorgl.,s"'.�',L '& Address & `10 icense NoPhone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION CI Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR QK, OTHER p Monitoring Well L7 <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom 0 Manteca pia. of Well Excavation Dia. of Well Casing <br /> I(Oomestic/Private ❑ Gravel Pack L7 Tracy Type of Casing Specifications <br /> Pubfic i-1 Other 0 Delta Depth of Grout Seal <br /> Type of Grout <br /> G Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Dona Type of Pump H.P. ^- State Work Done <br /> jF <br /> Well Destruction 0 Well Diameter Sealing Material i Depth <br /> Depth Piller Material 3 Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION Ll REPAIR/ADDITION 0 DESTRUCTION GI (NO septic system permitted if public sewer is <br /> Installationmavailable within 200 feet.) <br /> 0rcial <br /> will serve; Residence. Com — Other <br /> Number of living units: Number of bedrooms <br /> Character of evil to a depth of 3 feet: t Water table depthSEPTf <br /> TANK ❑ Type/Mfg ' Capacity— No. Compartments <br /> r , PKG.kG. TREATMENT PLT. C7 f Method of Disposal <br /> ,r. <br /> Distance to nearest: Well ""Foundation Property Line <br /> LEACHING LINE C1 No. & Length of lines r t Total length/size <br /> FILTER BED _ [_l Distance to nearest: Well FoundationProperty Line <br /> f , <br /> SEEPAGE PITS 11 Depth Size J- 4 <br /> SUMPS L"l Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 ;. a <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 <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 shalt not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following; "I certify that in the performance of the work for which this permit is issued, f shall employ persons subject to workman's compensa- <br /> tion laws of Californla." i <br /> The applicant must cAll for all required inspections. Complete drawing on reverse side. <br /> Signed + <br /> Title: Date: <br /> F R PARTMENT USE ONLY f <br /> Application Accepted by Date <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Date <br /> Additions! Comments; <br /> Applicant – Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOR 2409, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE j AMOUNT HEMiTTED CK <br /> " [NFO CASH RECEIVED BY DATE ;PeAmrr-NO. <br /> 1REV. <br /> E>i;6.16 C <br />