Laserfiche WebLink
(1� I <br /> APPLICATION FOR PERMIT `1• <br /> l. b <br /> e <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 7 <br /> ENVIRONMENTAL HEALTH DIVISION ND ��1 dna � <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> RES 1 YEAR FROM D T ED <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 /> v Joaquin County Public Health Ser s. <br /> ` Job Address City Lot Size/Acreage <br /> I <br /> Owner's Name• --� iS�� e Address 36 S- Phone 2 <br /> x Contractor � Address ti� !f License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C} DESTRUCTION D Ou f Service Well D <br /> PUMP INSTAL ❑ SYSTEM REPAIR ❑ p Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK WER LINES L FLD. PROP. LINE <br /> FOUNDATION AGRIC RE OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL P REA CON9 TION SPECIFICATIONS <br /> f-1 Industrial �DOpen B ❑ Manteca Dia. of Well Ex ion Dia. of Well Casing <br /> C7 Domestic/Private el Pack C1 Tracy Type of Casing Specifications <br /> I'I Public C3 Other f-1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation T .Approx. Depth I I Eastern Surface Seal Installed by r <br /> Repair Work Done U Type of Pump H.P. State Work Done J <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 DESTRUCTIONX INo septic system permitted if public sewer is <br /> available within 200 feet.l <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. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. D Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE LI No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Welt Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Welt Foundation Property Line <br /> DISPOSAL PONDS © . <br /> I hereby certify that I have prepared this application and that the work wilt 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 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." <br /> The applicant st II II 'nspe, ions. C ate drawing on reverse side. !� <br /> Signed X ills: C�1 � � Date: 7 +�/ <br /> X <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by oat <br /> t <br /> 61 <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Servicesr Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMIrtED GASH RECEIVED BY DATE PERMIT NO. <br /> . EH 13-24{REV.1 i n si SQ �0 _ <br /> EH 14-26 I <br />