Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
APPLICATION FOR PERMIT <br /> 4 1 1 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ` 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 200 , STOCKTON, CA 95201 <br /> PERMIT EX IRES1 1 YEAR FROM DAIS ISSUED <br /> (ComplLete 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 1$62 and the Rules and a tions of San <br /> Joaquin County Public Health Services. <br /> al <br /> Job Address <br /> City Lot Size/Acreage <br /> Owner's Name --A A 10 _ `- ,'Address,, )_! Phone C <br /> Contractor Address Z/0 A License No +St3 9Z Phone 4 <br /> TYPE OF WELL/PUMP: �, NEW OELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> � Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE W L OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREAJDif <br /> UCTION SPECIFICATIONS ' <br /> 1 Industria! L3, Open Bottom ❑ Manteca Well Excavation Dia. of Well Casing <br /> 1") Domestic/Private ❑ Gravel Pack C] Tracy Casing • SpecificationsI"I Public f:1 Other n Delta -Grout Seal i Type of Grout <br /> Irrigation Approx. Depth I 1 Eastern ""- Seal Install d�by <br /> Repair Work Done L7 Type of Pump,• H.P �` �r"rState{Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material,&`Depth <br /> Depth Filler Material & Depth i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t REPAIR/ADDITION I I DESTRUCTION I'1 lNa septic system permitted if public sewer is <br /> /� available within 200 feet.) <br /> Installation will serve: Residence Y Commercial her - <br /> Number of living units: Number of"bedrooms <br /> Character of soil to a depth oh feet: � / Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity_ _V 0 Q — No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> t Method of Disp sal <br /> f Distance to�nesrest: Well oundation Property Line • <br /> LEACHING LINE' ❑ No. &.Length of lines To al length/size <br /> FILTER BED ` ❑_ pistance to nearest: Well / 't7 oundation Property Line <br /> x <br /> SEEPAGE PITS l I Depth Sire N ber i <br /> SUMPS LI Distance tone est: WelI�Foundation�_ property Line <br /> DISPOSAL PONDS 1) <br /> t <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, 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•contracdng signature <br /> certifies the following: "I.certify that in the performance of the work for which this permit is issued, I shall employ <br /> tion laws of California." V y persona subject to workman's compensa- k <br /> The applican ust call reverse side,uirinspections. Complete drawing on <br /> Signed X Title: Date: <br /> FORD NT U8E_ONLY <br /> Application Accepted by G—�-� <br /> Date Area <br /> Pit or Grout Inspection by Date Final Inspection by �Q <br /> bx, <br /> Date. <br /> Additions! Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health t <br /> I Services, Environmental Health Permit/Services s <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE A DONT DUECK AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> CASH --._.. .-. __.... }i <br /> + EH 13-24(REV.1/145) b c)-1VV <br /> y <br /> EH 71.20 <br />