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 /> f� P O BOX 2009, STOCKTON, CA 95201 <br /> 1 RMIX MIRES__1„YEAR FROM DATE ISaWM <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 complisace with Ban Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> w .] ( <br /> Job Address ' ; rth1 ON A4 F- City PAuTeCit __ Lot Size/Acreage <br /> /V ICk MCIA"tS/S <br /> Owner's Name��� Address Phone <br /> Conitaclor____1_I_ 'l ___ A IS Address / U �ZT2A) AVC License No.2.e13`i17 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT>❑:. ,,DESTRWCTION ❑ Out of Service Weli ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR C) OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Ci Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications_ <br /> I'I Public I-1 Other f"1 Delta Depth of Grout Seal Type of Grout <br /> t I Irrigation —Approx. Depth I I Eastern .Surface.Seal Installed by---� ,� <br /> Repair Work Done U Type of Pump x_ H.P.._ _ _State Work — <br /> Done--Well Destruction O Well Diameter i Sealing Material & Depth s h <br /> Depth Filler Naterl&V Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 l REPAIR/ADDITION Vr DESTRUCTION I I INo septic system permitted if public sewer is i <br /> rf available within 200 feet.! <br /> Installation will serve: Residence Z Commercial_ Other ' <br /> Number of living units. _L Number of ooms <br /> Character of soil to a depth of 3 feet: E114m } i <br /> Water table depth � <br /> SEPTIC TANK. ❑ Type/Mfg 4 Capacity � No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation { Property'�Line r <br /> LEACHING LINE f�Dista <br /> o. & Length of lines Toiat length%size s <br /> FILTER BED na to nearest: Well /00 Foundation ` 1 Property Line a <br /> A DINf 1CTeL gP17 <br /> SEEPAGE PITS I I Depth 1 Size Number s lr <br /> SUMPS LI Distance to nearest: Weil Foundation Property Line - <br /> DISPOSAL PONDS ❑ ' <br /> i <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 • 4 _ t t <br /> Home owner or licensed agent's signature certifies the following: "I certify"that in the performance of t eoW rk 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 subcontracting signature <br /> certifies the following: "I Cartify 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 /> Tha applicant must call for all requir nspections. Complete drawing on reverse side. I <br /> Signedx— Title: Date: 6- •G /' /o <br /> 1 ti <br /> FORI <br /> Application Accepted by kA,, Date Area <br /> !r # <br /> Pit or Grout Inspection by Date f Final Inspedtidn by } Date <br /> Additional Comments: 1 <br /> Applicant - Return all copies to: San Joaquin County Public Health 111 <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 ox 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CKw RECEIVED BY <br /> INFO RECE <br /> H DATE Z'IiRMiTNO. <br /> a EH 13.21 tNEV.I/x51 <br /> EH ! _�-q, 0— /633 <br /> � 1.4-20LOr(� (� �0.. Sr) (Q .. <br />