Laserfiche WebLink
t <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PMIT EXPIRES 1 YEAR FROM DATE5�SUED <br /> (Complete in Triplicate) <br /> Application is hereby made.to San Joaquin County for s <br /> permit to construct and/or install the nark herein described. This i <br /> application is made in compliance with San Joaquin County Ordinance No. 51+9 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. r. <br /> Job Address City hot Size/Acreage 2 I <br /> (3 <br /> Owne('s Name r' 'r Address­�a C,_) 1 . ' �� KPhone <br /> .. �.�, _ w------ �...... ..+ �.�....�., i ��`` <br /> Contractor dress Jr License NovLPhone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION-LO Out,of. Service Well 0 <br /> Mlonitorin Well <br /> C, PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ i $ C7 <br /> DISTANCE TO NEAREST;?SEPTIC TANK SE ER L ES DISPOSAL FLD. - PROP. LINE <br /> I 'FOUNDATION AG ICU TUBE WELL OTHER WELL PITS/SUMPS <br /> INTENIDED USE TYPE OF WELL PROBLEM 4piA CONSTRUCTION SPECIFICATIONS <br /> 1) Indusfriii ❑ Open Bottom ❑ MantecDia. of Well Excavation Dia. of Well Casing <br /> FI Domestic/Private. <br /> ❑ Gravel Pack ❑ Tracy Type of Casing Specificationsr <br /> I'1 Public (.1 Other n Dalt Depth of Grout Seal Type of Grout <br /> I I Irrigation ,Approx. Depth I Eastern Surface-Seal-1nstailed-by <br /> . -- — <br /> Repair Work Done (3—Type of Pump /10 f H.P. I State Work Done_ <br /> Well Destruction ❑ Well Diameter, Sealing Material & Depth r•. <br /> .p { DeptF► y'` Filler Material pth <br /> TYPE OF SEPTIC WORK': NEW INSTALLATION.1„11 REPAIRIADDITION iT TRUCTION I I INO se is system permitted if public sewer is <br /> i e _ vaila within 200 feet.) <br /> Installation will serve: Residence,Cbmmercia! 9t or e�, n, <br /> Number of living units: Number of "drooms� ;Y <br /> Character of soil to a depth of 3 feet:, -° Water table depth <br /> i SEPTIC TANK 0 Type/Mfg Capacity U No. Compartments <br /> PKG. TREATMENT PLT. ❑ r <br /> Method of Disposal (f) <br /> Distance to nearest: Well.._!2_J 9MFoundation_L� Property Line 6 ` <br /> LEACHING LINE Cl No. & Length of lines610 Total length/size U'G'H` <br /> FILTER BED ❑ Distance to nearest: Wel! Foundation 10 Property Line <br /> " 4 r <br /> SEEPAGE PITS 11 - Depth Siie ` Number <br /> SUMPS LI Distance to nearest: Well F.oundation � Property Line <br /> DISPOSAL PONDS ❑ �_ e <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 I 1, d <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 subcontracting signature <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." i ' <br /> The applican ust call w8lf erbire�-inspection sCo <br /> . mplete�'�drawing on reverse side. r <br /> Signed � Title: _ Date: <br /> 2 i <br /> =- - <br /> USE ONLY 1 <br /> Application Accepted by <br /> RODate �L Area <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 <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEEr <br /> t INFO MOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. <br /> f <br /> •�EH 1 EH {2EIAEV.iin5s 0,`Q� V <br />