Laserfiche WebLink
(J 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 BOX 2009, STOCKTON, CA 95201 <br /> PEMIT l- <br /> EXP RES 1 YEAR FROM DA TE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made.to San Joaquin county for a <br /> permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 5119 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address _J'.�6 2 S A,, e L C✓h c�� ,n„ <br /> /p " City Lot aize/AcreageZQ jm.. <br /> ,ft, <br /> Owner's Name _!.I C_- CG, Address Phone Y6Z 7 <br /> Contractor j„jgL&.41w � Address A&IT'rx 6�3 License No. A S?�tl?D Phonee,?Z <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service We1.1 ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> 3 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> t Il Public Cl 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 ❑ Type of Pump H.P, State Work Done <br /> Well Destruction ❑ Wolf Diameter Sealing Material & Depth i <br /> Depth Piller Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION yREPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence x Commercial_ -Other <br /> Number of living units: Number of bedrooms 3 <br /> Character of soil to a depth of 3 feet: -Water table depth <br /> SEPTIC TANK' Type/Mig _}? � co-c.Yt.c,�C Capacity. 1({ O No. Compartments <br /> PKG. TREATMENT PLT, ❑ _y _ Method of Disposal <br /> 6 Distance to nearest: Well /0D� _ Foundation S Property Line _lij <br /> LEACHING LINE f, No. & Length of lines r Total length/size <br /> F FILTER BED ❑ Distance to nearest: Well Zoe—,-.Foundation a 1, <br /> . �� Property Line /v <br /> SEEPAGE PITS I De _ sy <br /> � pth Size� Number <br /> F+r SUMPS I_I Distance to nearest: Well Foundation l Property Line jp' <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 /> j tion laws of California.'. <br /> " The'applicant must call for all reci fired insPections. Complete drawing on reverse side. <br /> Signed'X C, ` Title: <br /> Date: <br /> OR DEPARTMENT USE ONLY <br /> IIYYF F 14 <br /> Application Accepted by Date �0 Area <br /> or Grout Inspection by Date Final Inspection b� Dat6� � <br /> Additional Comments: . <br /> Applicant – Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services �fM� <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY BATE PERMIT N0, <br /> f INFO CASH <br /> ',EH 13.24 PIEV.tiny <br /> EH A-26 C� '� ! (� .•�� ! _ac�l t �C/� <br />