Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
APPLICATIC£N+FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES r- <br /> ENVIRONIMTAL HEALTH DIVISION Jr <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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin CountAabl1c Health a ices <br /> _�_ I a <br /> Job Address Cit Lot 'lee/Acreage <br /> w q_� <br /> AV— <br /> s Na W o <br /> adress �L [�� e�)o Aa�)�1fFfione <br /> TYPE OF WELL/PUMP: NEW WELL/❑ WELL REPLACEMENT f 1 ESTRUCTION 0 Out of Service Well -Cl <br /> PUMP INSTALLATIoi SYSTEM REPAIR 0 OTHER ❑ Monitoring Well 0 <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 /> � 0 pd�ustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> �yS.B6mastic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> x/11 Public f:I Other n Delta Depth of Grout Seal type of Grout <br /> I I Irrigation _.Approx. rn Surface Saul Installed by <br /> Repair Work Done 0 Type of Pump H.P. � State Work Done <br /> Well Destruction 0 Well Dia �r Sealing Material & Depthr <br /> Depth Tiller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIWADDITION I I DESTRUCTION I I (No septic system permitted it public sower is <br /> available within 200 feet.) <br /> lnstatlation 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 ❑ Type/Mfg Capacity No. Compartments (1 <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> f Distance to nearest: Well Foundation Property Lina <br /> LEACHING LINE Cl No. 6 Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest:, Well Foundation—Property-Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS L1 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 /> Monte owner or licensed agent's signature certifies the fotlowtng: "-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 workman's compensation laws of California." Contractor's hiring or sub-contracting signature , <br /> certifies the followft: "I Cart' that in the performance of the work for which this ►mit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The appy t it call for al r 'ad i tions. Co/m�plete drawing arse si a. <br /> -�Lla 71 qf <br /> Sig U`t-' Tit Date: <br /> OR DEPARTMENT USE ONLY q A� <br /> Application Accepted by Date r Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: T <br /> Applicant - Return all copies to: ---San JoaquYn-Count y'PubT17c Htcal'th­ServiZ:s§-- <br /> Environmental <br /> §-""�— <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Hoa 2009, Stkn, CA 95201 <br /> FEErINFO " AMOUNT DUE- - AMOUNT REMITTED CK H ECEIVED BY - DATE-- - --PERMIT7NO. <br /> . EM 13-24(REV.tinSl � <br /> EH 14-211 � �"�T � Z9 — <br />