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 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISaUED ti <br /> (Complete is 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. 5h9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. jj <br /> Job Address F ry City Lot Size/Acreage w <br /> Owne�r�s Name M�r� "'Y1, dress A�� � Phone <br /> Contractor 11�t ��--- 1��c yr __Address 12 iscly License No Phone _ <br /> TYPE OF_WELL/PUMP: _ NEW WELL ❑ WELL REPLACEMENT P_ DESTRUCTION ❑ Out of Service,Well _ ❑, <br /> ~ PUMP INSTALLATION ❑ ..� SYSTEM REPAIR C) OTHER ❑ Monitoring Kell❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE' <br /> + FOUNDATION a AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i <br /> INTENDED USE TYPE OF WELL~ PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F y CI Industrial l- 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> fa Domestic/Private `+; ❑ Gravel Pack L] Tracy Type of Casing Specifications <br /> } <br /> I'I Public I:1 Other rl Defta Depth of Grout Seal Type of Grout "_ l <br /> + i I Irrigation t Approx. Depth I ) Eastern Surface Seal Installed by J <br /> i Repair Work Done, 0 Type of Pump H.P. T State Work Done _ <br /> Well Destructionf ❑ Welf Diameter Sealing Material & Depth <br /> Tflepth Filler Material & Depth r <br /> - s <br /> TYPE OF SEPTIC WORK:- NEW INSTALLATION 1 I REPAIRI.ADDITIONr DESTRUCTION iNo septic system permitted it public sewer is <br /> „available within 200 feet.) <br /> j Installation wil(serve: Residence__ Commercial Other <br /> Numbei'of living units: Number of bedrooms <br /> Character of soil to'a depth of 3 feet: S ti`[ L r5�s/fl t Water table depth <br /> SEPTIC TANK. Type/Mfg Capacity 75-7 - No. Compartments <br /> f PKG. TREATMENT PLT. ❑ µ. _ ._-� __,_f=_ _ � # • Method of Disposal <br /> Distance to nearest: Well __ Foundation�__� +' Property Line.' <br /> /LEACHING LINE � No. & Length of lines — Tota! length/size � � <br /> FILTER BED El j Distance to nearest Well_s n t Foundation D Property Line <br /> t SEEPAGE PITS I I Depth Size Number 1 <br /> r SUMPS LI Distance to nearest: - Well Foundation'- Property Line <br /> r, <br /> DISPOSAL PONDS ❑ <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 bf the San Joaquin County <br /> Home owner or licensed agent's'49nature 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 must call for all_r quire inspections. Complete drawing on`everse side. <br /> Signed Title: lfi s'tfi _ Date: 3 <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by 1 Date ;L` � Area <br /> Pit or Grout Inspection by 'Date k. Final inspection by Date <br /> rr <br /> Additional Comments: d v I <br /> Applicant ^ Return all copies to: San Joaquin County Public Health f aL� i <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE " AMOUNT REMITTED CASH CK I RECEIVED BY DATE PERMIT'NOe.• <br /> I l <br /> EH 13211REv.rinSf f �.� 3" {�J <br /> EH 14.26 <br />