Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby trade 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. �y I <br /> Job AddressCity Lot Size/Acreage 330 <br /> a n -305-- �� �s Ina <br /> ydz - <br /> Owner's Name � �Ad�dress / �,�_J� Phone <br /> y Conttac r Address s �! �b� [>CA��t , License No. z��7� Phone b 5�0l <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Ca Domestic/Private ❑ Gravel Pack C1 Tracy Type of Casing Specifications <br /> C) Public F Other I1 Delta Depth of Grout Seal Type of Grout <br /> i I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 -Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth �4 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATiON3< REPAIRIADDITION # I DESTRUCTION I I (No septic system permitted if ptiblic sewer is <br /> Y/ available within 200 feet.) <br /> Installation will serve: Residence_Aofooms Commercial____ ther <br /> J Number of living units: _ Numb �D �y{� <br /> Character of soil to a dept of 3 feet: Water table depth SEPTIC TANK Type/MfgCapacity No. Compartments <br /> PKG. TREATMENT,PL�. �1 y. f f i Method of Disposal <br /> / Distance to nearest: Well Foundation4' <br /> s!L Property Line <br /> LEACHING LINE No. & Length of•lines — Total length/size X <br /> FILTER BED Cl Distance to nearest: Well- — Foundation ftp Property Line SI-0_^ <br /> Af <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line^�R <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 /> 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." N <br /> The applican calk foruir inspections. Complete drawing on reverse si <br /> Signed Title: .2 Date: ' <br /> FOR DEPARTMENT USE ONLY <br /> ;.t <br /> plication Accepted by Date ?~�! ? Area . 1 Z <br /> or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <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 /> INFO <br /> FEE AMOUNT rDSUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> 9H 13-24(REV.1)851 <br /> %EH 14-26 <br />