Laserfiche WebLink
APPLICATION FOR PERMIT <br /> V <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> Ir, P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> t.. <br /> Application 1s 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 arid Regulations of San <br /> L <br /> Joaquin County Public Health Services <br /> , <br /> Q�j y,/�7^��'��� <br /> Job Address 443/0 d6- / / City 'rte 1.ot Siiz /Acreage <br /> LOwner's Name l44� Address 10ICJS /�j Phone <br /> dQ 1 /� <br /> Cont(aclM U OWA/ <br /> Af/ - �'" License No. �'07.d Phone �AOr <br /> L TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well Ll <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE _ <br /> OUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> LINTENDED USE TYPE OF WELL PR08 CONSTRUCTION SPECIFICATIONS' <br /> ❑ Industrial ❑ Open Bonom - ❑ Manteca Dia. o cavation Dia, of Welt'Casing j <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F) Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout V� <br /> t-- I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ G <br /> Well Destruction ❑ Well Diameter Sealing Material 4 Depth " <br /> �` Depth Filler Material i Depth _ ^ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION 1 I INo septic system permitted it public sewer is v) <br /> available within 200 feet.) <br /> F Installation will serve: Residence_& Commercial_ Other <br /> Number of living units: JF Number of bedrooms 2 <br /> Character of soil to a depth of 3 feet: ��n�L Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No.(Lompartments r <br /> 4 PKG. TREATMENT PLT.❑ - _ Method of Disposal , <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE OK No. E Length of lines I �a Total length/size d Z <br /> FILTER BED ❑ Distance to nearest: Well Foundation — - -Property Line ,]1 <br /> SEEPAGE PITS p( Depth SizeNumber` <br /> 3� <br /> tr SUMPS LI Distance to nearest: Well /Qs a Foundation Property Line 1� <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 /> r 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.",Contractofs hiring or sub-contracting signature <br /> certifies the following:"I certity that in the performance of the work for which this permit ivisstiod,I.shall employ parsons subject to workman's compensa <br /> tion laws of California." _ <br /> The applicant In t call for all required' pecf•ns. Complete drawing on reverse side <br /> Signed e �� Title: 1/ —S— 49 <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> r i <br /> Application Accepted by Date Area /� ' <br /> Pit or Grout Inspection by Date Final inspection by Date Z,,/— O <br /> r <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 /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATEig; <br /> O. <br /> EM 1}24 IREV.rrnW <br /> `ER 1.-as .,tTO I i-5-99 <br />