Laserfiche WebLink
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 /> REMIT EXPIRES 1 YEAR FR M UED <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 /> i application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations o San <br /> Joaquin County ]Public Health Services. 5 <br /> C] City Lot Size/Acreage <br /> Job Address 17 <br /> ._, <br /> Z_-04 l � 5 <br /> dress Phone <br /> Owner's Name jj <br /> Contractor <br /> Address° r- License IVoJ� Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL RLACEMENT _ DESTRUCTION 5 Out of Service Well LIEP <br /> PUMP INSTALLATION D <br /> SYSTEM REPAIR C1 OTHER ❑ Monitoring well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> l FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [I Domestic/Private _0 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> {'1 Public Cl-Other Il Delta Depth of Grout Seal � ` Type of Grout <br /> II I I Irrigation _ Approx. Depth 1 I Eastern Surface Seal Installed by <br /> Repair Work Done L7 Type of Pump H.P. "State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & D th <br /> Depth Filler Material pth _r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION DESTRUCTION I I (No septi cystithin m rented if public sewer isavailaby�`J <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. ❑ _ I Method of Disposal <br /> 'Distance to nearest: Well Foundation Property Line <br /> QQ <br /> LEACHING LINE ❑ No. & Length of lines _ �Q2 Total length/size 0 <br /> FILTER BED 1-1Distanceto nearest: Well� Poundation/.,Property Line <br /> SEEPAGE PITS 11 Depth —Site Number <br /> SUMPS Ll Distance to nearest: Well Foundation-lz,-3 Property Line W _ <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 /> i 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 /> 1 employ any person in such manner as to become subject to workman's compensation taws 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 cal rail required ' s cNons. Comp to awing on reverse side. <br /> Signed X Title: Date: <br /> 77 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> ��� Y1/� Date Z`� r Area 1 <br /> Accepted -- <br /> i Pito Grout Inspection b; � Dam Final Inspection by <br /> t Additional Comments: <br /> 1 <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 /> IFEENFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED By DATE PERMI7'NO. <br /> . EH 13-21 tREV.iim6) (2- <br /> EH 11.26 •--�- <br />