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 BOB 2009, STOCBTON, CA 95201 <br /> V ^ <br /> PERMIT EXPIRES 1 1 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 /> I <br /> ` Job Address City Lot Site/Acreage <br /> ___ _ _ . _ .. _._ <br /> Owner's Name Address <br /> Contractor Address License No. 3zone <br /> TYPE OF WELL/PUMP: NEW WELL Q WELL REPLACEMENT O DESTRUCTION O Out of Service Well O <br /> PUMP INSTALLATION D SYSTEM REPAIR O -- OTHER O Monitoring Well 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP: LINE <br /> FOUNDATION AGRICULTUREVE OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA STRUCTION SPECIFICATIONS <br /> O Industrial ❑Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack ❑ T Type of Casing Specifications <br /> I'1 Public n Other Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _ Approx. pth I I Eastern Surface Seal Installed by (�. <br /> Repair Work Done 13 Type o mp H.P. State Work Done <br /> Well Destruction .O Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEP WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial, Other <br /> Number of living units: -_. Number of bedrooms <br /> Character of soil to a depth f 3 feet: Water table depth <br /> SEPTIC TANK. depth <br /> Capacity -''No. Compartments Ell__ <br /> PKG. TREATMENT PLT.0 Method of Disposal <br /> Distance to nearest: Well_foundation Property Line <br /> l Oa�T Total le.�th/size m O <br /> LEACHING LINE No. & Length of lines � g s� <br /> FILTER BED ❑ Di s ance to nearest: Well foundation Zdlt/_�Property Line <br /> SEEPAGE PITS I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation roperty Line <br /> DISPOSAL PONDS ❑ , II <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 O <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 noto <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 mu or all required in Y ns. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> �D FOR DEPAR�L�EENT USE ONLY <br /> Application Accepted by '!Via E°�czR11 �. [-L.-� Date L , �/ Area' <br /> Pit or Grout Inspection by J" Date Final Inspection y DataP <br /> ` <br /> Additional Comments: L <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E,=Hazelton Ave.,,;P O Boi*2009, Stockton, 'CA 95201 <br /> IFEE <br /> NFO AMOUNT DUE - AMOUNT R`EMITTEI) CASH RECEIVED BY DATE PERM17•NO. <br /> . EN13.21(REV.1/8 5) <br /> EH 1428 <br />