Laserfiche WebLink
9 f! <br /> APPLICATION FOR PERMIT <br /> EC $� � SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> t AUG � � ����li ENVIRONMENTAL HEALTH DIVISION <br /> I 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> s ENVIRONMENTAL hcALTH P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT/SERVICES PRN7T EXPIRES 1 YEAR FRQM DATE 191SUEP <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 County Public Health Services. ! <br /> it1110 ,< C ze/Acreage <br /> Job Address <br /> rr ---� <br /> (� Phone <br /> i Owner's Name <br /> A&L o trac r icense No. Phone <br /> C <br /> TYPE Of WELL/PUMP: _ NEW WELL 0 WELL REPLACEMENT DESTRUCTION Ll Out of Service We11 L1 <br /> PUMP INSTALLATION ❑ SYSTEM REPA Monitoring Well OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL VL 07 PROP. LINE <br /> _ FOUNDATION. AGRICULTURE WELL OTHER WELL- PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS <br /> I Dia. of Well Casin <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Oia. of Well Excavation g <br /> tnestic/Private ❑,Gravel Pack ❑ Tracy Type of Casing -- I Specifications <br /> l'1 Public FI Other fl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation 11 .Approx. Depth I I Eastern Surface Seal Installed by. i <br /> Repair Work Done><Type of Pump H.P. _ ate' or oa — <br /> Well Destruction O Weil Diameter Sealing Material & Depth f' I <br /> Depth Filler Material & Depth „ <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I ,REP AIR4ADDITION_I_1_.DESTRUCTION I I (No septic system permitted if public sewer is ly <br /> ' available within 200 feet.I "h1 <br /> { Installation will serve: Residence�Commercial=Other <br /> Number of living units: !Number of bedrooms - I <br /> I Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK: © Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ " f Method of Disposal <br /> r -1 D stance to nearest: Well Foundation Property Line <br /> r LEACHING LINE ❑ No.4 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 I Depth Size Number <br /> SUMPS it d Distance to nearest: Well Foundation F 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, <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: 1 certify that in the pa lotmance of the work for which this permit is issued, I shall not <br /> employ any person in such rsiannet as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this'per it is issued, 1 shall employ persons subject tow rkman's compensa- <br /> tion laws of California." <br /> The applican u call f d ins ctions. Complete drawing o re fse side.', <br /> Sig ed Date. <br /> i <br /> k � FOR DEPARTMENT USE ONLY <br /> /� t <br /> Application Accepted by Date a Area <br /> Pit or Grout Inspection by 'p t Data Final Inspection by Date <br /> yAdditional Comments: " } <br /> r <br /> Applicant – Return all copies to: San Joaquin County Public Health <br /> o Services, Environmental Health Permit/Services <br /> I 1601 E. Hazelton Ave.. P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT OtiE AMOUNT REMITTED CK 8 CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> . Eli 13.24(REV.iirl5) ir <7 <br /> }.� C <br /> - 1 J <br />