Laserfiche WebLink
F <br /> 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 BOIL 2009, STOCKTON, CA 95201. <br /> EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) �: 1 �'7-Z�0--1 y <br /> tt S ., : <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 Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. -14II0 (-q- <br /> JW <br /> q' <br /> cmrswe'oF � �,y� Q1 A RQ City_ Y I Lot Size/Acreage <br /> Job Address <br /> � yU <br /> b•-SZ" <br /> Owner's Name AddressPhone <br /> Conhactor LkA1�nnh�� �,�`�N� - LicenseNo.5 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 /> C1 Industrial ❑'Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> FI Domestic/Private Cl Gravel Pack 0 Tracy Type of Casing Specifications <br /> Il Public 1-1 Other fl Delta Depth of Grout Seal <br /> Type of Grout <br /> muauon ..App(ox. Depth l I Eastern Surface}Saa_I Installed by <br /> Repair Work Done Type of Pump H. —I�� - State Work Done <br /> Well Destruction © Well Diameter Sealing Material & Depth �7- <br /> Depth Filler Material & Depth,,. <br /> TYPE OF SEPTIC WORK: NEW-INSTALLATION I I REPAIRIADDITION I I DESTRUCTION l I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other 4 t-y <br /> Number of living units: Number of bedrooms r r t+ <br /> Character of soil to a depth of.3-feet:=! - '- 'i -- # Water table depth <br /> SEPTIC TANK. ' ❑ ' Type/Mfg t Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ i t 1 f Method of Disposal t <br /> I :t, ,► }- :f �_Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No.---& Lengih--o'f°liries�-1- Totatilength/size <br /> FILTER BED 0 Distance to nearest. Well Foundation Property Line <br /> p <br /> SEEPAGE PITS I I Depth Size 'Number <br /> SUMPS cF ; r Ll rVistance to nearest: Well Foundation �` Property Line <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'agert'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 sublect'to workman's compensaiinn laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the pertormance.of the work for which this permit is issued, I shal4 employ persons subject to workman's compansa- <br /> tion taws of California." <br /> The applicant m call for all required inspection . Complete drawing eve aside. <br /> Signed X Title: Date: <br /> f .F l k ti s 3 R DEPARTMENT USE ONLY <br /> Application Accepted by <br /> I Date 7 1� d ! Area <br /> Pit 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., F 0 Boxf2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE J PERMIT-NO. <br /> INFO CASH n <br /> r EH 13-24{REV.I/Ft5) pp oO <br /> EH t4.2e <br />