Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 i <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT MIRES 1 YEAR FRPM_DAZE USUED <br /> (Complete in Triplicate) <br /> r <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 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. ! �/ <br /> Job Address 1-0 i z r'^t City O�� Lot Size/Acreage /7- <br /> CAm2A�' p�vElclhE�+TT' Address ! l-ae��ca. �Q�v� f 9 (��b 3 -t ' <br /> Owner's Name Phone <br /> .. n <br /> Contractor 1,A-4 E44114M/�J/� Address & <br /> 613E J96ZEd License No. Zo 700 Phon§J�� <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ I <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Monitoring well C� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLDL1�-,111w.ZINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI S 7-0 iD OL-e- ! <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation_ Y Dia. of Well Casing <br /> 11 Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> I'I Public (:I Other f1 Delta Depth of Grout Seal r X Type of Grout- L- G ; <br /> t I Irritation _._...Approx. Depth ( I Eastern Surface Seal Installed by <br /> Repair Work Done . ❑ Type of Pump H,P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth 50!L. /S 1 H <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <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. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> i <br /> LEACHING LINE CI No. & Length of lines Total length/size ' <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line i <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 st call for all r aired inspections. Complete drawing on reverse side. <br /> Signed v• Title: 4`T//041 te: / <br /> FQ DEPARTMENT USE ONLY <br /> Application Accepted by Date 2_/9 <br /> _7ZG/ Area �✓ _� <br /> Pit or Grout Inspection by Date Final Inspection by Date T t { <br /> Additional Comments: 0d f1OLLIC _ A C42 cl Vl +-e crC <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 /> FEEINFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> . <br /> EM 13-24(REV,I/A 5) S� �y. SGS'' IN 1 -7• 9- ai4-4(o4jj <br /> EH 1620 <br />