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 /> PERMIT EXPIRES 1 YEAR FROM DATE ,ISSUED G 0")(Complete in Triplicate) J <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 /> A / <br /> Job Address &"ze; City Lot Size/Acreage <br /> Owner's Name_ - Address L d T /Ir Phone <br /> Contractor + Address ac.S. License No. APhone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT i7 DESTRUCTION ❑ Out of Service well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REP 0 OTHER ❑ Monitoring well [7 <br /> .DISTANCE TO NEAREST: SEPTIC TANK SEWE LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION:. AGRI LT WELL OTHER WELL PITS/SUMPS _ <br /> t <br /> INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom, . ❑ M eca Dia. of Well Excavation Dia. of Well Casing <br /> EI Domestic/Private ❑ Gravel Pack Tracy Type of Casing ' Specifications <br /> I') Public CZ Other n Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation Approx. pth t I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump 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 fl ;AIH/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is � <br /> available within 200 eet.) �\ <br /> I Installation will serve: Residence_ Commercial ther <br /> Number of living units: Number of bedrooms . <br /> Character of soil to a depth of 3 feet: Water table depth \ { <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments ` <br /> PKG. TREATMENT PLT.❑ Method of Disposal �1 <br /> Distance to nearest: Well Foundation Property Line { <br /> LEACHING LINE D No. & Length of lines Tota 49th/size \` <br /> FILTER BED ❑ Distance to nearest: We C <br /> I SEEPAGE PITS 11 Depth SizA/.fft0f/&4Xndation <br /> _ umber. <br /> SUMPS L] ' Distance to nes est: WeA� Property Line <br /> I 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 compensatibn 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 appTAccepted <br /> ll for ired in ctions. Complete drawing on reverse side. <br /> Signed Title: ._.�� Date: <br /> FOR DEPARTMENT USE ONLY! <br /> Applicatby Date Area ��f <br /> Pit or Grout Inspection by Date Final Inspection by ' Date fd ! <br /> Additional Comments; Z-ia, U4ZZ, <br /> Applicant - Return all copies to: San Joaquin County Public Health^`--' <br /> Services, Environmental Health'Permit/Services <br /> 1601 E. Razelton Ave., P 0 Box 2009, Stockton,- CA 95201 <br /> jINFOAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY PATE PERMIT'NO. <br /> I + EH 1324(ACV,f h$1 <br /> EH 14.26 C r fj-fin, <br /> t <br />