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 /> k EXPIRES 1 .YEAR FR M D TE <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 /> St 6t Dotaw— City <br /> Lot Size/Acreage <br /> i <br /> Job Address <br /> i Phone <br /> Owner's Name.- � dress /��Q� q <br /> Contractor <br /> Address icense NoA . �QQ9 Phone "`;4 <br /> TYPE OF WELLIPUMP: NEW WELT Monitoring.NeTl`�� <br /> ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> OTHER ❑ j <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ r' <br /> SEWER LINES DISPOSAL FLD. PROP. LINE o <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS : <br /> FOUNDATION - AGRICULTURE WELL OTHER WELT <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> n Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Specifications_ - <br /> C1 Domestic/Private ❑ Gravel Pack n Tracy Type of Casing <br /> Depth of Grout Seal Type a1 Grout <br /> !'1 Public L-1 Other n Delta <br /> 11 Irrigation —.Approx. Depth I I Eastern Surface Seal installed by <br /> Repair Work Done ❑ Type of Pump <br /> H P ' State Work Dona _ <br /> Sealing Material & Depth <br /> Well Destruction O Well Diameter Filler Material & Depth <br /> Depth <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 14-1)l STRUCTION i I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial)Other \tom 1V <br /> Number of living units: Number of bedrooms )" <br /> " t- Water-table-depth--,- <br /> Character <br /> depth--,--Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Capacity _ No. Compartments <br /> Method of Disposal e <br /> PKG. TREATMENT PLT. El """' t <br /> Distance to nearest: Well Foundation 1--� Property Line' <br /> LEACHING LINE EL-t+l" Length of lines <br /> Total length/ <br /> FILTER BED El Distance to nearest: Well Foundatio D Property Line I <br /> I SEEPAGE PITS I I Depth Size <br /> Number <br /> f <br /> SUMPS stance to no rrgsst: Weil Foundation . f n- Property Line Q <br /> DISPOSAL PONDS I-] C/ o1Kx a— s' '3� <br /> I hereby certify that I have prepared this application-and that the work will be done i accordance with San Joaquin county ordinances, state laws, and <br /> I y <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following, 111 certify that in the performance of theworkfor 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 /> 1 do Is California." <br /> f r� <br /> The applicant Il ilO\li equied ins co[onsComple[e drawing on re+terse side. <br /> Q , '� a .Title: — - -Oats: <br /> Signed X .__ <br /> ! FOR, EPARTMENT USE ONLY <br /> I x Application.Accepted by <br /> Date 7 r r [ _�— Area { <br /> Pit or Grout Inspection by Date Fina! Inspection by <br /> Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit_/Servi-ces <br /> 1601 E. Razelton'A_ve., P 0 Box,2009, Stockton, CA 95201 <br /> A <br /> FEE AMOt3NT Dt1E AMOUNT REMITTED C K 8 RECEIVED BY ATE tPEMIT'NO.INFOEH 13.2/IREV.r/M51 O '� -77 <br /> t EH 44-26 - <br />