Laserfiche WebLink
v <br /> 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 BOR 2009, STOCKTON, CA 95201 <br /> SIT 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 /> �ob Address IV16 eJut City AOi✓Lot Size/Acreage <br /> �dwner's Name iXE� .����- Address 159.3 / �/y�T _ Phone ��� �'LY 7 57 <br /> rContractor Q_Gy/2C-1— Address License No. Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR C7 OTHER L7 Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISP6AL FLD. PROP. UNE <br /> FOUNDATION AGRICULTURE WELLTHER WELL PITS/SUMPS _ <br /> INTENDED US F WELL PROBLEM AR STRUCTION SPECIFICATIONS <br /> L-) Industrial C] Open Bottom nteca Dia. of Well Excavation Dia. of Well Casing <br /> f7 Domestic/Private c ❑ Tracy Type of Casing Specifications <br /> I't Public 1-1 Other Cl Delta Dep rout Seal Type of Grout <br /> I I Irrigation .w.Approx. Depth I I Eastern Surface Seal Ins by <br /> Repair Work Done U Type of Pump H.P. St rk Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION t INo septic system permitted if public Sewer iS <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial____ Other yh <br /> Number of living units: Number of bedrooms f/7� <br /> Character of soil to a depth of 3 feet: ` Water table depth V <br /> SEPTIC TANK. ❑ Type/Mfg _ Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE L'1 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS 11 Depth Size _ Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <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 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 subcontracting 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 appnt mus all for all squired spa;t' ns. Complete drawing on reverse side. <br /> XSigned Title: - /?cam" „ ,._,._. Data: _ I <br /> FQR DEPARTMENT USE ONLY <br /> .r <br /> Application Accepted by ' Date 7'��" Area i <br /> Pit or Grout Inspection by Date Final Inspection by Date ` "L <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 CASH RECEIVED BY DATE f ERMIT'NO. <br /> Aft <br /> i <br /> . EH13.21 SREV.IINs> p <br /> EH 1426 <br />