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 BOA 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 Services. <br /> Job Address Lot Size/Acreage <br /> Owner's Name Ld - '� !„�/�'o l/ ✓ `t Phone <br /> ( <br /> Contractor Address License No. Phone_ <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 NEARES K SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION A WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUC ECIFIDAIS-w ­ <br /> CI Industrial ❑ Open Bottom ❑ Manteca Dia. of WeII ExcaGaon Dia. of Well Casing <br /> -.. <br /> Ca Domestic/Private ❑ Gravel Pack ❑ Tracy ,. ..... "'Type of Casing ecifications <br /> ("I Public CI Other eta Depth of Grout Seal Type o N <br /> I I Irrigation — �. epth I I Eastern Surface Seal Installed byRepair Work Dor "f3- Type of PuH.P. State Work Done _ <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth filler Material 8 Depth <br /> TYPE OF SEPTIC WORK: •NEW INSTALLATION j I REPAIR/ADDITION I I DESTRUCTION 4,INo septic system permitted if public sewer is ^ <br /> ailable within 200 feet.) U J <br /> Installation will serve: Residency tea'Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposalt <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line , <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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-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 applicat call for all required inspections. Complete drawing on reverse side. I <br /> mus <br /> Signed ! c- - t-C¢�. itle: �[ `�1���ii Date _` <br /> 'Fib1ENT USE ONLY t <br /> Application Accepted by S.I1C�� Ar, Date Area <br /> Pit or Grout Inspection by Date Final Inspection by _ Date <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 /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATER PERMIT'N+O. <br /> r EH 13.21►REV.r/e sr C p _14r vv t O C7 <br /> EH 42e J <br />