Laserfiche WebLink
5 ~, <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 BOR 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED_ <br /> 6?37 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 /> , r Lot Size/Acres e <br /> Job Address City Size/Acreage <br /> Owner'i Name Address Phone 0�9 <br /> "V <br /> / qq�� ^�/ / o <br /> Contract r* Address �U. /67 7. r License No. Z Phone fao S�0 _` <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service .Well ❑ ` <br /> PUMP INSTALLATION 13SYSTEM REPAIR 0 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 /> i <br /> * industrial ID Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> * Domestic/Private ❑ Gravel Pack D Tracy Type of Casing Specifications <br /> I'} Public Cl Other F1 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 U Type of Pump r H.P. State Work Done ; <br /> Well Destruction © Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR! DOITION I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: 'Residence Z Commercial_ Ot r r <br /> Number of living units: :1— 'Number of edroom <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, 0 C Method of Disposal <br /> Distance to nearest: Well Foundation Property Line i <br /> LEACHING LINE ❑ No. & Length of lines _ _ Q Total length/size <br /> FILTER BED Distance to nearest: Well LO_ Foundation ---/,Q Property Line <br /> s <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 f . <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 y' <br /> Home owner or licensed agent's signature certifies the following: "I certify that inihe 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 compensa(lon 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." <br /> The applic ust call t r fired inspections. Complete drawing on raver c s' <br /> Signed X Title: Date: <br /> OR DEPARTMENT USE ONLY / <br /> Application Accepted by Dto /�sArea �0 <br /> Pit or Grout Inspection by Date Final Inap�tion byZr 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 —O <br /> FEECK <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY `� "' DATE PERMIT'NO. <br /> « EN 13-24 TREY. <br /> Ell 74.Ie d(/ - <br />