Laserfiche WebLink
ter. <br /> z 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 O BOX 2009, STOCKTON, CA 95201 <br /> PRAMIT EXP RISS 1 YEAR FROM D%T9 ISSUED <br /> (Completer 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 <br /> Joaquin County Public Health Services. of San <br /> KJob Address 1�Ce 3 W - l� / Ae e V- City �� Lot Size/AcreagQv aClreS <br /> Owner's Name _ _ C�Yl n„ �L` lQ 1r i tiC Q Address ro1 t fr Phone 4 )3 _ <br /> Contractor Address License No. <br /> Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ LL REPLACEME Cl <br /> ❑ DESTRUCTION Out of Service We11 0 <br /> PUMP INSTALLATION ❑ YSTEM REP IR ❑ OTHER C) Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE LL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONST CTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. We Excavation <br /> Dia. of Well Casing <br /> 11 Domestic/Private ❑ Gravel Pack Ll Tracy Ty of Casi <br /> I'I Public Specifications <br /> C7 Other C-1 Delta pth of Grout eal Type of Grout <br /> I I irrigation _.Approx. Depth I I Eastern Surface Seal Insta ad by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction 0 Welt Diameter Be ing Material & Depth <br /> Depth F Iler Material &.Depth I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRlADDITION i I DESTRUC jON IN septic system permitted if Public sower is <br /> ailable within 200 feet.) <br /> Installation will serve: Residence_ Commercial.— .� <br /> Other <br /> Number of living units: Number of bedrooms " <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK. Water table depth <br /> ❑ Type/Mfg Capacity <br /> PKG. TREATMENT PLT. C1 No. Compartments <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size r <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth N <br /> Size ; `r d w , <br /> -- - - umber- _ <br /> SUMPS (l Distance to nearest: Wel! Foundation <br /> DISPOSAL PONDS ❑ Property Line <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 taws, an <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 no <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, t shall employ persons subject to workman's campensa <br /> tion laws alifornia." <br /> The app) an us <br /> II all r ired inspections. Complete drawing on reverse side. <br /> Signed % t <br /> Title: Date: <br /> OR DEPARTMENT USE ONLY <br /> Applicata n Accepted by <br /> Date Area <br /> Pit or Grout Inspection by date <br /> Additional Comments: �r +� U O 1 �', J,� L)" ' <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 /> EEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PERMIT'NO. <br /> a EM 13-24IREV.iin5i 0 �a � �7 <br />