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 O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 ecatiliance with San Jequin ounty Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. 8 <br /> Job Address 4410 1® E ' L_60 T I� f ��. t Size/Acreage p <br /> ErLW <br /> Owner's Name Address D /t Phoneco <br /> I <br /> �U r l._H Addy— �``SS� ��96D55ucertse No.3SS6� Phane'�T�3 <br /> Contracto Address�TV� <br /> ,TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 17 DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 /> Ci Industrial 0 Open Bottom ❑ Manteca Dia. of Welt Excavation Dia. of Well Casing <br /> C1 Domestic/Private ❑ Gravel Pack* ❑ Tracy Type of Casing_ Specifications "C i <br /> it Public 1"1 Other fl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by 0 <br /> -Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction 0 Well Diameter Sealing Material i Depth <br /> Depth Filler Material 4 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIRIADDITION I I DESTRUCTION 1 No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soli to a depth of 3 feet: Water table depth 1 <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.C] Method of Disposal ." <br /> Distance to nearest: Well Foundation Property Line <br /> 0 . <br /> LEACHING LINE Cl No. b Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest. Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Lina <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 regufations 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 wo(kman'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,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applica Call to alt req eii s. Complete drawing verse side. <br /> Signed Title: ..., r,� Date: <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by Date Area �— <br /> Pit or Grout Inspection by Date Final Inspection by Data °I <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 O Box 2009, Stkn, CA 95201 <br /> CKA <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> popo <br /> . EH 114.26 IREV,Mks) y, 7 y,.�- <br /> fH tt-26 <br />