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 /> EXPIRES 1 YEAR FROM DATE ISSUM <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 conpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. t <br /> Job Address � City Lot Size/Acreage <br /> Owner's Name Drz�vAddre s� Phone f.7-1 121 <br /> �//` 7ope-1 0 1A <br /> Contractor Address License Phone <br /> TYPE OF WELL/PUMP. W WELL WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well <br /> SYSTEM REPAIR ❑ OTHER C7 Monitoring Well <br /> PUMP INSTALLATION ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION ! AGRICULTURE WELL OTHER WELL f PITS/SUMPS , <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Z Dia. of Well Casing <br /> Domestic/Private Gravel Pack ❑ Tracy Type of Casing— Specifications <br /> I'I Public 11 Other fl Delta Depth of Grout Seal T pe of Grout <br /> I f Irrigation clw-Approx. Depth I 1 Eastern Surface Seal Installed by Al <br /> Repair Work Done ❑ Type of Pump 5V,6_ H.P. _ State Work Done T <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 13 REPAIR/ADDITION l I DESTRUCTION I 1 Mo septic system permitted if public sewer is <br /> -available within 200 feet.l <br /> Installation will serve: Residence_ Commercial— Other <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 No. Compartments <br /> PKG. TREATMENT PLT, 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest. Well Foundation Property Line <br /> SEEPAGE PITS 1 I Depth Size _ Number <br /> SUMPS L I 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 cenifies 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 workritan'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 . afl r r ctions. Complete drawing on reverse gide, <br /> Signed X Title: �� ^• Date: <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by 6.ADate Area <br /> Pit or Grout Inspection by S Dated Final Inspection b r Date! <br /> Additional Comments: 1— <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 /> AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE l PERMiT'NO. <br /> a EH13-21MSI.1/n5� , •_1�•-9! <br /> EH 1 .26 rr r lQL <br />