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 O BOX 2009, STOCKTON, CA 95201 <br /> _PYAWIT 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 /> pp <br /> Job Address �� <br /> ` � ✓O 11. t!�i� F� CityLot Size/Acreage <br /> Owner's Name � �t.zil�G4/ er6fs Address no <br /> Contractor Address 1�0� Z�� ,n IS <br /> License No. t��-f p_r _ Phene <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT(❑ DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIPJ❑ OTHER ❑ Monitoring Well [3 <br /> DISTANCE TO NEAREST: SEPTIC TANK 'SEWER1INES I�_ DISPOSAL FLD. _ _. PROP. LINE <br /> FOUNDATION AGRICULTURE WELC'�-.,,_l 'OTHER',WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU&ION SPECIFICATIONS <br /> L_-} industrial ❑ Open Bottom ❑ Manteca � � Dia. of,Well Excavation Dia. of Well Casing <br /> -n <br /> C] Domestic/Private ❑ Gravel Pack L1 Tracy Type of Casing Specifications <br /> 'l Public IJ Other fl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth I I Eastern + Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work 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 DESTRUCTION I 1 Mo septic system permitted if public sewer is <br /> available within 200 feet.l <br /> Installation will serve: Residence Commercial Other � C <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 Nb. Compartments ' (f <br /> PKG. TREATMENT PLT. ❑ Method of Disposal T� <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE `Q( No. & Length of lines Total length/size <br /> FILTER BED C] Distance to nearest: Well Foundation Pr9perty Line <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS ll 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 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 applicant must call for all ui(ed inspections. Complete drawing on reverse side. <br /> l - j <br /> Signed X Title: eg <br /> Date: <br /> ICOR PEPARTM.ENT USE ONLY— —. G <br /> Application Accepted by Date 7 ` ' 11 Ares a 6 <br /> Pit or Grout Inspection by Date Final Inspection by Date Sd <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permlt/Services <br /> 1601 E. Hazelton Avd., P 0 Box 2009, Stockton, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH _ RECEIVED BY DATE /�PEAMIT.NO. . <br /> Iff - _" _ 0_�- <br /> + EH 13"24 tREV.I)n5) Jv <br /> fJlo -�'� /^I <br /> FH 91.2a <br /> IJrJ <br />