Laserfiche WebLink
APPLICATION FOR PERMIT <br /> 4 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> UIT EXPIRES 1 YEAR FRPM DAIE IPSUED <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 /> Job Address 2'0250 •S V� City <br /> _ � Lot Size/Acreage <br /> rt 15 84 Phone <br /> " Owner's Name 7`« �,���-+�� - _-- Address ��-_.-._-,� - <br /> Contractor Address -► >� License No. r�S- T Phone_ <br /> TYPE OF WELL/PUMP:- I! NEW WELL ❑ WELT. REPLACEMENT El DESTRUCTION ❑ out of Service Well 0 <br /> 'PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER p Monitoring Well L7 <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 <br /> t i Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> N Domestic/Private ❑ Gravel Pack p Tracy Type of Casing Specifications <br /> V1 Public is Other n Delta Depth of Grout Seal Type of Grout <br /> i I Irrigation ��.Approx. Depth I I Eastern Surface Soul Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> i, Well Destruction 0 We111 Diameter Sealing Material & Depth I. <br /> Filler Material b Depth b <br /> h. Depth <br /> f TYPE OF SEPTIC WORK: NEW INSTALLATN REP I l DESTRUCTION l I (No septic system permitted if public sewer is <br /> 1� available within 200 feet.] <br /> IO <br /> instaflation will serve: Residence 2v Commercial Other <br /> Number of living units: "41 !_ Number of bedrooms' �` '• <br /> .. 1 <br /> ^ Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ fType/Mfg L • Capacity No. Compartments <br /> �I°! PKC. TREATMENT PLT, ] ' ✓ Method•of Disposal <br /> Distance to nearest' ' Welf/ Foundation Property Line <br /> � Vr <br /> F LEACHING LINE No & Length"of lines To6l~length/size <br /> FILTER BED 0 Distance to nearest. Well� Foundation;__1 1.,—-7 Property Line � <br /> • ,Ili: ,.._ . -�,« .•,r�� I <br /> s SEEPAGE PITS 11 Depth f Size Number + <br /> SUMPS CI Distance to nearest: Well Foundation Property-Line <br /> -DISPOSAL PONDS ❑ w. <br /> hereby certify that I have prepared this applicatign and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> i .rules and regulations of the San Joaquin County <br /> }Home owner or licensed agent�,s,vgnature certifies the following: "f certify that in the performance of the work for.which this permit is issued, I shall not <br /> 'employ any persoh in.such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature <br /> T. <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." II <br /> ` 1 The applicant must call for a required inspections:Complete drawing on reverse side. <br /> Signed X Title: Date: –vfG�"& <br /> FOR DEPARTMENT USE ONLY � <br /> Application Accepted by Date 2 Area <br /> - <br /> Pit or Grout Inspection by, I� Date Final inspection by Date � 2r <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 /> CK <br /> a <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO., CAA SH % . <br /> ! <br /> y <br /> EM rllL ; c h2.N2'l' Ir �p T <br />