Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O SOS 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 ' <br /> YATE USUIR <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. s <br /> , <br /> application is made in couplisnce, with San Joaquin county Ordinance No. 549 and 1862 and the Rules estd Regulations of San <br /> Joaquin County public Health Servicea. <br /> i; <br /> Lot Size/Acreage ,I <br /> kJob Address City <br /> Phone <br /> Ko <br /> wner's Name ddres <br /> ss <br /> XCGMractor <br /> Address License No. — <br /> — Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C] DESTRUCTION , Out,Mf Service Well ❑ <br /> ;I � OTHER O Monitoring Well L7 <br /> PUMP INSTALLATIONSYSTEM REPAIR ❑ <br /> - <br /> SEWER LINES DISPOSAL FLO. POOP, LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITSISUMPS <br /> FOUNDATION AGRICULTURE: WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS k <br /> fl Industria! E3 Open Bottom C] Manteca [)is. of Well Excavation Dia. of Well Casing <br /> Type of Casing. �T,'" 5pecilications.. - <br /> U Domestic/Private ❑ Gravel Pack 11 TracyXype of Grout <br /> M Public to Other C] Delta Depth of Grout Seal . - <br /> k0 Irrigalion .�.'.Approx, Depth 0 Eastern """"Surface Saul Installed by <br /> Repair Work Dane U Type of Pump H.P. State Work Done _ <br /> Sealing Material i Depth T- <br /> Wall Destruction O Well Diameter Piller Material i Depth " <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION J2REPAIR/ADDITION 0DESTRUCTION Cl (No sbavale'within 200 foetc syslek�}ed d pubiic sewer is <br /> I <br /> Installation will serve: ResidenceCommercial— 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 D Type/Mfg Capacity No. Compartments <br /> Method of Disposal.`` <br /> PKG, TREATMENT PLT. 0 <br /> Distance to nearest: Well Foundation Property Line #. <br /> k <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> I FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> r <br /> SEEPAGE PITS 11 Depth Size _ _--_ Number <br /> i SUMPS LI Distance to nearest: Well r Foundation Property Line <br /> j 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 fotlowing "I certify that in the performance of the work for which this permit is issued, I shall not <br /> an's compensation Laws of California." Contractor's hiring or subcontracting signature <br /> employ any person in such manner as to become subject to workm <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." <br /> : The applicant must call for�ll required inspections. Complete drawing on reverse side, �l Q <br /> Vigned Title: Date: -1 r + Qr ! <br /> S p ONLY <br /> DatArea <br /> Application Accepted by <br /> e `` <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional 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 O BOX 2008, STOCKTON, CA 85201 <br /> FVM <br /> AMOUNT REMITTED CK RECEIVED BY DATE PERMII'NO. <br /> CASH <br /> r 3-7-��1 -lj ivD <br /> f-.-•�, PA 0-0 <br /> O V .✓`rr // /'� <br /> 1�_s' .a .ice -- C/ /- 0 <br />