Laserfiche WebLink
APPLICATION FOR PERMIT , � <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES l <br /> ENVIRONMENTAL HEALTH DIVISION , <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERiIIT EXPIRES 1 YEAR FROM-DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin County for e <br /> 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 GP�ublic Health Services../, -�^ <br /> Job Address ` !a �Q _Z� �� i - City Q Lot Size/Acreage <br /> Owner's Name."` (�/ ddress Phona= rX '/ <br /> Contraclor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION O 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 SPECIFICATION_S <br /> Cl Industrial © Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> F1 Domesticl Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> !'1 Public f-1 Other n Delta . Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done O Type of Pump H.P. State Work Done_ \ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION INo septic system permitted if 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 soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. . 0 Type/Mfg CapacityT �"- —No:"Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & 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 Cl 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 workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify" <br /> ertify t 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 /> 4he appy a t must call06 r a squired inspectio s. Complete drawing on reverse side. �- <br /> gned Title: �­111h�.1Y���------ Date: ^ <br /> OR DEPARTMENT USE ONLY [�F fes) <br /> ..1�..,L......_..— rJ <br /> Application Accepted by � Date (�"�� Area <br /> Pit or Grout Inspection by Date Final Inspection by 'v Date,:? <br /> a <br /> Additional Comments: i <br /> Applicant - Return all copiesl:: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Ser"� es <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stocktb , CA 95201 <br /> 1FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> . EH 13-2 tRfV. /n51 '� J �— L.5- v ��—IwZ`l <br /> EH 4-M L (� <br />