Laserfiche WebLink
_Z IA <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION N� <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby 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 - City sSKD( M'CVot Size/Acreage <br /> Owner's Name ` Address � ` - 2--� Phone C 581 - <br /> Contractor Address License No. Phone_ <br /> YPE OF WELL/PUMP: NEW WELL O 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: PT <br /> TANK SEWER LINES DISPOSA PROP. LINE <br /> FOUNDATION AGRICULTURE WELL HER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLE ONSTRUCTION SPECIFICATIONS <br /> n Industrial O Open Bottom anteca Dia. ell Excavation Dia. of Well Casing <br /> C:l <br /> Domestic/Private O ack O Tracy Type of Casing. Specifications <br /> I'1 Public fa Other n 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 _ (n <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> _ vT' <br /> Depth ClIn 14LIt & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I PAIR/ D I I DE 1 tNo system Permitted if public sewer is <br /> a thin 200 feet.I <br /> Installation will serve: Residence_ Commercial l� .l <br /> Number of living units: Number of bedrooms Wolk b n eXPired withoo <br /> Character of soil to a depth of 3 feet: yVU1►( ,ee1n� r®( nl., .� _ Water table depth <br /> SEPTIC TANK O Type/Mfg ` 7 Capa i y o�peGt,,�y . Compartments <br /> PKG. TREATMENT PLT. O 1tT :aF�ealth ©i�, Jiol l lethod of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 11 No. & Length of lines Total length/size <br /> FILTER BED O Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size _ Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line , <br /> DISPOSAL PONDS O <br /> 1 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." <br /> The applicant ms c I for all required nspections. Complete drawing on reverse side. <br /> igne Title: ®l X­1 ,cam Date: 7— �Q <br /> A, FO D P RTMENT USE ONLY ' <br /> Application Accepted by Date S V. � 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., P 0 Box 2009, Stockton, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED <br /> INFOBY DA}TEE PERMIT'NO. <br /> + EH 13-24(REV.riMsl �0 <br /> EH 91•Ie 12 � ,V \G l <br /> �,f l <br />