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 BOR 2009, STOCKTON, CA 95201 <br /> PFaMIT EXPIRES I YEAR FROM DATE- ISSUED <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 /> Job Address e- -- City Lot Size/Acreage / AW— <br /> Owner's Name � - Address l'llt;I_� Phone 3&_ y-3 <br /> Contractor Address _ eg� License No. :36S;W 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 /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 17 Domestic/Private 0 Gravel Pack ',.off El Tracy 168 of Casing Specifications <br /> I'1 Public Ll Other n Delta �,Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth .L€ I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter tSesling Material 8 Depth <br /> Depth _Filler Material R Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ' REPAIR/ADDITION DESTRUCTION I k iNo septic system permitted if public sewer is <br /> available within 200 leet.l <br /> Installation will serve: Residence_ Commercial___._ Other <br /> Number of living units: . „_ Number of b drooms <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. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines ���� Total length/size .Sri <br /> FILTER BED ❑ Distance to nearest: Well `J��? Foundation Property Line VOf JZ <br /> SEEPAGE PITS I6- Depth -� c�~ Size rr Number Z_ <br /> SUMPS Ll Distance to nearest: Well.LQ 1�.1. Foundation d r Property Line j:5- <br /> DISPOSAL <br /> SDISPOSAL 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 /> �F. <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 canify 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 must call for all rs fired ' spections. Complete drawing on reverse side. <br /> Signed _._ Title: b` �t a[.� Date: r3 O <br /> flR D TMENT USE ONLY <br /> d <br /> Application Accepted by Date Area <br /> ,Pit,4r Grout Inspection by Date inal inspection by . DateC1 <br /> C-11y <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> s 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> INFO AFEEMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY !1 DATE PERMIT'N . <br /> 0 <br /> . EH 14-241REV,r/HSi <br /> E!1 744E VIA �� \ � 3J� J�• �_1`16 \© _?A1 <br /> J C <br />