Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> lJ° 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOR 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 <br /> h Serervvices. /d�� // ,. �//'� <br /> Job Address 1q696 �> "" -0' 12 P) City ��/ Lot Size/Acreage ILI <br /> (( t, Ry, <br /> Owner's Name borl,� n r Cif® Address ZNpti Phone <br /> Contractor Address CU1 dense No. S IS Phone <br /> 2^ 6 <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 f <br /> n Industrial ❑ Open Bottom ❑ Manteca., Dia. of Well Excavation W! Dia. of Well Casino <br /> omestic/Private Gravel Pack ❑ Tracy Type of Casing FZ, Zfo P,4 C Specifications d <br /> ['I Public fl Other n Delta Depth of Grout Seal So 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 161 <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth ``{\•` <br /> Depth Filler Material & Depth <br /> TYPE OF TIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: 'dence_ Commercial_ Other <br /> Number of living units: her of bedrooms <br /> Character of soil to a depth of 3 feet: star table depth <br /> SEPTIC TANK ❑ Type/Mfg capacit No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: W>ell ation Property Line <br /> LEACHING LINE ❑ No. & Length of I' <br /> eslength/size <br /> FILTER BED ❑ Distance eart: Well Foundation y Line <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPO PONDS ❑ <br /> I he y 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, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant or all r inspections. Complete drawing on re erse side. \ <br /> Signed Title: �v " Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date � - Area <br /> Pit or tarouOnspection by V ,Date -77 Final Inspection by-�.�/� �il�d. <br /> � ZzJ.A Date � O <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 /> IEEE MOUNT DUE AMOUNT REMITTED C SH JRECEIVED BY DATE /yPERMIT'NO. <br /> + EH13-24(AEV.1/95) /')rO� bl o / �,/ �6 y-_,,26 <br /> EH A-26 (/ 11 (,� L <br />