Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby amide 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 County Public Health Services. <br /> "1 Job Address I oZ5 J' <br /> + City Lot Size/Acreage <br /> 4IJ <br /> %ntractor <br /> nar's Name ' F AddressA4A 3 ? / ^ Phone 57 <br /> ,rp <br /> Address o-9 ��(1 � License No. Phone -� <br /> TY OF WELL/PUMP: NEW WELL O WELL REPLACEMENT'n DESTRUCTION Out of Service Well <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL w OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS' <br /> Cl Industrial O Open Bottom ❑ MantecaDia. of Well Excavation Dia. of Well Casing- <br /> PKDomestic/Private O Gravel Pack ❑ Tracy _ Type of Casin 11 <br /> g_ Specifications <br /> Il Public (-I Other n Delta - Depth of Grout Seal Sit Type of Grout <br /> Irrigation _.Approx. Depth 1 l Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump �» H P.� State Work Done _ <br /> Well Destruction O Well Diameter SeaingrMaterial i DepthILI <br /> Depth !iller Material i Depth \`fit• <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) �J <br /> Installation will serve: Residence_ Commercial_ .Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.O Method of Disposal <br /> Distance to nearest: Well• Foundation Property Line <br /> LEACHING LINE 'Ll No. b Length of lines Total length/size <br /> FILTER BED O Distance to nearest: Well Foundation Property-Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI 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 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 shall not <br /> employ any person in such manner as to become subject to work man'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, I shall employ persons subject to workman's compensa- <br /> tion laws of California." ---The applicant must call for all required inspect s. Complete drawing on reverse side. <br /> Signed TitDate: <br /> �FORARTMENT USE ONLY. cp <br /> Application Accepted byDate T Area <br /> / 5g/W-A-L-0115 *fle-v� <br /> Pit or Grout Inspection byDate Final Inspection by Date <br /> Additional Comments: 1�1 0 Dvj `0 O <br /> Applicant - Return all copies to: San Joaquin County Public Health Services Cil ( � e ng etf (� <br /> Environmental Health Permit/Services J (, <br /> 445 N San Joaquin,--P-O Box 2009, Stkn, CA 95201 Otrl4( ALCeWliFEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERRpM1T'NO. 1 " <br /> . EH t0 <br /> C, ? <br /> 1 ' IREV,1/85) <br /> o 0,cro & , - <br /> EH 114.n 2! W V C!C 3-4°53 73- <br />