Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468- 734l-� <br /> p&`WIT URIHNS 1 YF PROM DATE MUM <br /> U <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 <br /> JCounty <br /> Puu►bliic Health Services. <br /> ob Address4J IiA A/" I s.''^ � ��"�(' <br /> City Lot Size/Acreage <br /> dm) <br /> CC <br /> /Owner's Name `� Address T ` '"" ' �'� hone ` <br /> COnlraclw �Y`s.�lcS.�l� Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL C1WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well Cl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C OTHER ❑ <br /> Monitoring Well ❑ <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 /> E-1industrial Cl Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing <br /> U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing _ _ Specifications <br /> M Public —13 Other– ❑ Delfa -Depth of Grout Seal ^t^ Type of Grout <br /> J � <br /> n Irrigation —Approx, Depth ❑ Eastern L_I rSurfaca Seal_Instatlted <br /> Repair Work Done,xU—Type of Pump H.P. State Work Done , <br /> Sealing Material 4 Depth 1 <br /> Weil Destruction \\❑ Well Diameter f <br /> \\ \ Depth Filler Material Ir Depth <br /> TYPE OF SEPTIC WORK-: NEW INSTALLATION ID REPAIR/ADDITION M OESTRUCTiON INo septic system permitted if public sewer is <br /> availabls within 200 fest.l <br /> Installation will serve: R dente— Commercial Other <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of,3 feet: <br /> SEPTIC TANK. O Typ\e/.Mfg Capacity No Compartments <br /> ` <br /> PKG. TREATMENT PLT. UMethod of Disposal1 � � •♦ <br /> Distance to nearest: Well 1`, - Foundation Propeny Line <br /> LEACHING LINE O No. 3'Length'of lines-L'— <br /> FILTER <br /> ` Total length/size <br /> ♦ �' \ Property Line <br /> BED ❑ Distance�to nearest: Well Foundation pe Y <br /> SEEPAGE PITS 11 Depth \ Si:eti=� t Number�� <br /> SUMPS LI Distance to nearest: Wall !F'1 Foundation Property Line <br /> DISPOSAL PONDS ❑ �`'k i\ L Z <br /> I hereby certify that I have prepared this application'end That the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rubs and regulations of the San Joaquin County \'^ i` <br /> Home owner or licensed agent's signature certifies the following: "I certify that i tithe performance of the work for which this permit is issued, 1 shall not <br /> employ any person in such manner as to"Come subject_to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the peel ormance'o!'tfie_work for which•this perrr>t is issued, I shall employ persons subject to workman's Componsa• <br /> tion laws of Wfornia." <br /> jhe appliuri s I Or all roqu mplete.drswtng on reverse side. q <br /> �[_ Date: <br /> i <br /> yyy"`444gned T iUe: 4 <br /> R DEPARTMENT USE ONLY <br /> � p <br /> l Application Accepted by eC �� .� Date ' 'C Area <br /> 1 \ W A.t A� <br /> Pit or Grout Inspection by Date Final Inspection by Date 2 b <br /> Additlonol Comments:• \ ,\ <br /> Applicant – Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PfiRMIT/SERVICES <br /> i 445 N SAN JOAQUIN. P 0 BOX 2009; STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMrT'TEO CASH RECEIVED BY DATE PERMIT NO. <br /> INFO �} I (�(� {^�/� M r Q <br /> l EM 13.24(REV.rinse 1� �,OO �� { w 11 <br /> 3li/01l <br /> FM:s.�b 111 [ 11 <br />