Laserfiche WebLink
APPLICATION FOR PERMIT _C _ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES J <br /> ENVIRONMENTAL HEALTH DIVISION VJ O <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 ` <br /> P O BOX 2009, STOCKTON, CA 95241 <br /> ESP RE 1 YT R FR D ED <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:Wo. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. ? �y <br /> Job Address Size/Acreage �- —j <br /> 3 <br /> �^Owner's Name ' iAddress <br /> \x Conlraclor Address Licensee No. Phone <br /> TYPE OF WELL/PUMP: EW WELL ❑ WELL REPLACEMENT 11- DESTRUCTION ❑ Out of S rvice Well ❑ <br /> PUMP INSTALLA SYSTEM REPAIR ❑ OTHER ❑ itoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK LINES DISPOSAL FLO. ROP, LINE <br /> FOUNDATION AGRtCULT ELL OTHE PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTR ECIFICATIONS r <br /> 1-7 Industrial ❑ Open Botiom ❑ Manteca Well Excava r` Dia. of Well Casing <br /> e r <br /> Cl Domestic/Private �. ❑ Gravel Pack . L7 Tra Type of Casing __ Specifications <br /> i'1 Public #1:�._Other,-, Delta Depth of Grout Seal Type of Grout <br /> I 1 IrrigatiOn x. Depth l I Eastern Surface Seal Installed by <br /> M <br /> Repair Work Don ype of Pump H.P. State Work Do e <br /> Well Destruction 0'.." Weil Diameter 1 sealing Materiel & Depth 1 <br /> _3 Depth Filler Material & Depth j <br /> TYPE OF SEPTIC.WORK:. .NEW-INSTALLATION I I,: REPAIR/ADDITION l I .DESTRUCTION LINO septic system permitted if public sewer is <br /> available within 200 feet.) s� <br /> lnstalladon will serve: Residence -4 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 r Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ } Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Ll No. & Length of lines Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line <br /> t <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS El Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that 1 have prepared thisaapplication and that the work will be done in accordance with San Joaquin county ordinances, state laws, and s <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'ecome 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, 1 shall employ persons subject to workman's compensa- <br /> tion taws of California." 1 <br /> The applica t must call for all required oinspections. ConnDlete drawing on reverse side. <br /> Signed r Title: —&Zow� -- „-. Dots: <br /> M FOR DEPARTMENT USE ONLY <br /> Application Accepted by � Date "�' <br /> - Area <br /> Pit or Grout Inspection by Date Fine! Inspection by OM+ Date cr� <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 <br /> INFO AMOUNT DUE � AMOUNT REMITTED CK a CASH RECEIVED BY DATE PERMIT"NO. <br /> SOEH 1440 `- <br />