Laserfiche WebLink
s ii�r <br /> APPLICATION FOR PERMIT � <br /> SAN dOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION � <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOR 2009, STOCKTON, CA 95201 <br /> D7tRl(TT E%PIRES 1 YEAR FR M DATE �SSiIED <br /> (Complete is 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 /> r. <br /> City Lot Size/Acreage <br /> Job Address <br /> 7s7 Phone <br /> Address <br /> Owner's Name .�- -� <br /> Address License No Phone <br /> Contractor <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ,❑ <br /> PUMP INSTACLATION�C] SYSTEM REPAIR C7 <br /> OTHER 0' Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK .. - SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION "'� 4' 'AGMCULTURE WELL OTHER WELL PITS/SUMPS t <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> •------ pia. of Well Casing <br /> {.1 Industrial ❑ Open Bottom,,,__,._Q MantecaY _,,...,-,Dia. of,Well-Excavation <br /> f:l Domestic/Private L GIavel Pack ❑ Tracy <br /> Type of Casing 3 Specifications <br /> Cl Delta Depth of Grout Seal f Type of Grout <br /> I'1 Public Cl Other � <br /> I I Irrigation —iApprox. Depth I I Eastern Surface Seal Installed by <br /> of Pump�� H State Work Done <br />'€ Repair Work Done O Type ! <br /> I r Sealing Material & Depth <br /> Well Destruction © Well Diameter i-' `444 0 Filler Material Depth r <br /> Depth TtA <br /> I� TYPE OF SEPTIC WORK: NEW INSTALLATION �REPAI�F ADDITION I l DESTRUCTION I I sYst <br /> available septic shin 200 feetern .] if public sewer is <br /> r S� i <br /> Installation will serve: Residence Commercial _^ Other j <br /> 7 k vF <br /> Number of living units: _ Number-of-bedro* <br /> Character of soil to a depth of 3 feet: {t } Water table #depth <br /> Ta/Mf r r 7�n__� No. Compartments <br /> SEPTIC TANK. ' yp g Capacity_. -- s� - <br /> 4y` } Method of Disposal <br /> PKG. TREATMENT PLT. Ll i <br /> ( I / <br /> Distance to nearest: We`II'- Foundations ProPertY Line / <br /> 1. <br /> ` { e „Z �Q� Total length/size C �ttC <br /> LEACHING LINE +� No. &`�ngth of linesi— - � <br /> Foundation Property Line —r9 <br /> FILTER BED o Distance tti nearest: Well , <br /> SEEPAGE PITS Depth t f Size Number 1 3 <br /> SUMPS Ll Distance to nearest: Well ^ Foundation_ Property Line <br /> DISPOSAL PONDS ❑ r <br /> prepared this pp llcatiod.and that the work will be done in accordance with�the work far which this permit is issued, I shall not <br /> San Joaquin county ordinances, state laws, and <br /> k I hereby certify that ! have prepY f. <br /> I` rules and regulations of the San Joaquin CountYr' <br /> Home owner or licensed agent's signature,oertifit§s the following"i certify that in the performance of nie':}ubjec}-to workman's compensation laws of California:" Contractor's hiring or sub-contracting signature <br /> employ any person in such manner as to beao <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 campensa <br /> tion laws of California." _ ,,� <br /> i The applicant m t calk for ell r�qu'ed iri ctions. Complete drawing on reverse side. qJ <br /> Title: Date: <br /> Signed <br /> FO EPARTMENT USE ONLY /% <br /> Application Accepted by <br /> Date—L-AJ--C1 Z) Area <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin Colony Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE CK RECEIVED BY DATE PERMIT'NO. <br /> INF AMOUNT DUE AMOUNT REMITTED CASH <br /> • EH 13-24+REV.r i n 5) <br /> EH 14-2e <br />