Laserfiche WebLink
APPLICATION FOA 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 IL YEAR R M "ATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to Sen. Joaquin County for a permit to construct and/or install the vork 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 /> S l S I <br /> � � City r Lot Size/Acreage <br /> Job Address <br /> Address �`' Phone <br /> Owner's Name <br /> CG9 Address r"� r 7 License No 7731 S Phone <br /> �� r <br /> Contractor �T'� ---- <br /> WELL REPLACEMEN7'§� DESTRUCTION put of Service Well ❑ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ OTHER ❑ Monitoring well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> t SEWER LINES DISPOSAL FLO.. PROP. LINE <br /> DISTANCE TO NEAREST: <br /> SEPTIC TANK PITS/S MPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS fl <br /> Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Industrial ❑ Ops � /rte SpBc`ifications ! Y <br /> Type of Casing } <br /> 'O`Dornastic/Private f�Gravel Pack ❑ Tracy • Type of Grout <br /> ['1 Public Cl Other r f1 Delta Depth of Grout Seal l X15 4^ <br /> n ,, 1 <br /> I I Irrigation a��ta Approx. ;Depth l 1 Easterp, - Surface Seal Installed by <br /> ^E State Work Done i <br /> Repair Work Done $k"Type of-Pump — H. <br /> .11 Sealing Material i Depth <br /> Well Destruction► ❑ well Diameter' <br /> Depth- <br /> Depth D 1 'i� ]tiller Material & Depth <br />` TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 13 DESTRUCTION l I availableic SYSIOMw thin l00 ffeett;ed it public sewer is <br /> 16 <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of wit to a depth of 3 feet: <br /> SEPTIC TANK. ❑ Type/Mfg 1 Capacity_ h1o• Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT.D - <br /> Distance to no Well Foundation Properly Ciiie�' <br /> LEACHING LINE ❑ No. lti-Length of lines Total length/size <br /> FILTER BED ❑ Distance tit nearest. Well Foundation Property Lina <br /> i i r <br /> SEEPAGE PITS I ] pept Sire Number <br /> SUMPS Cl Distance to, nearest: Weil=- Fooundstion -Property Line <br /> DISPOSAL PONDS ❑ s <br /> I hereby certify that l 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 Oaunty �" * of <br /> Home owner or licensed agent's signature certifies the following: 'I certify that in�he.pertormance of thirwork for which this permit is issued, <br /> ampby any parson in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting nature <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 co penes <br /> tion laws of California." k 1 � ..�- - r 7 _ "�'� <br /> The applicant must II for all required inspections. Complete drawing on reverse side. -e <br /> Signed x, -� <br /> } __ Title: 66'r' - _._ Date: 0 <br /> FOR DEP RTMENT USE ONLY f <br /> ! _ Date 6/ Area .. _ . <br /> Application Accepted by _ <br /> Pit or rout nspection'by <br /> Date 4E Final Inspection by Data <br /> Additional Comments: <br /> Applicant Return 1 copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> p 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FE CK RECEIVED BY ATL? PERMIT ND. <br /> 1 IiE <br /> E AMOUNT RE�Mj}fTI ED /j <br /> V <br /> i . EH 53.94 II1EV-t/Rsl Q�C� <br /> [, EH 14.38 r` <br /> - <br />