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 /> PFJWIT EXPIRES 1 YEAR FROM DATE IS5UED <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 <br /> Health Services. <br /> � �O' City Lot' Size/Acreage 1 <br /> Job Address � ' r <br /> Owner's Name !/ 7�4 Address 's• Phone <br /> ContractorAddress J� "`'� �a License No.�_' ?11Phone! � °3 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION O Out of Service Well O <br /> PUMP INSTALLATION O SYSTEM REPAIR O OTHER O 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 O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private O Gravel Pack ❑ Tracy Type of Casing Specifications <br /> i'I Public Cl Other (l 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 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 I REPAIR/A-909QN DESTRUCTION I I Mo septic system permitted if public sewer is <br /> available within 200 feet.) (� <br /> Installation will serve: Residence v Commercial_ Other I <br /> Number of living units: Number of bedrooms �-- <br /> Character of soil to a depth of 3 feet: y L d),i'. Water table depth o r <br /> SEPTIC TANK Er Type/Mfg - Capacity /C- " No. Compartments — <br /> PKG. TREATMENT PLT, O Method of Disposal <br /> Distance to nearest: Well o ( Foundation 46 Property Line f <br /> LEACHING LINE L4—No. & Length of lines P _Total length/size ` <br /> FILTER BED 0 Distance to nearest: Well 4W / Foundation �S / Property Line <br /> r` <br /> SEEPAGE PITS ("I—Depth r 1 Size Number 2-- <br /> SUMPS LI Distance to nearest: Well l VW Foundation �_ Property Line <br /> DISPOSAL PONDS O <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, 1 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, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The app icant must call fIrsilir inspections. Complete drawing on reverse side. <br /> Signed Xy �� Title: d`o't-S-A Date: �� f <br /> ^' !�i�D�E�PAARTMENT USE ONLY Z <br /> �-"'�' _ Area <br /> Application Accepted by ',L"//��/�J Date �! r <br /> 6)or Grout Inspection by '� Dater Final Inspection by //� Data [ <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 /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMI1*NO. <br /> INFO CASH <br /> + EH 13.24(REV.ries) �VM0-33vl <br /> EHg4•25 , a LLL <br />