Laserfiche WebLink
a <br /> APPLICATION FOR PERMIT j <br /> SAN JOAQUIN COUNTY:.PUBI;IC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> I [PIRES 1-YEAR FROM <br /> DATR 198 <br /> " (Complete in Triplicate) <br /> j 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 /> ! ��(] <br /> Job Address <br /> �4�0 ,dzg5L TOR/ City S7K� Lot Size/Acreage <br /> C,r S��f?� Phone 1169-9LI Z <br /> Owner's Name _ Address W,? <br /> r <br /> Cont+actor �GQ Y,V W 8� Address ress <br /> ,gat�LBei�T A License No. ���� phone GS 39111, <br /> WELL REPLACEMENT El DESTRUCTION L) Out of Service Well 0 <br /> TYPE Of WELL/PUMP: NEW WELL f� <br /> PUMP INSTALLATION. ❑,, s. SYSTEM REPAIR ❑ <br /> OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION} AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> ] Industrial ❑ Open Bottom El Manteca "Dia.`of Well-Excavation <br /> Type of Casing Specifications <br /> f Ca Domestic/Private ❑ Gravel Peck ❑ Tracy.f yp <br /> I'l Public f 1 Other n Delta Depth of Grout Seal Type of Grout 1 <br /> ! T <br /> i I } Irrigation �.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 r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l 1 DESTRUCTION I 1 INo 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 m <br /> Character of soil to a depth of 3 feet: SA Water table depth <br /> SEPTIC TANK ❑ Type/Mfg ��'t- Capacity 12-0 0 No. Compartments Z <br /> PKG. TREATMENT PLT. ❑ j Method of Disposal <br /> Distance to nearest: 7- Well Foundation Property Line <br /> + € <br /> LEACHING LINE CR'No. & Length of lines Total IengthJsize <br /> : Al Foundation /A ` Prop rtyLine 4- <br /> FILTER <br /> FILTER BED 0 Distance to nearest.,.-e . Well- � . <br /> SEEPAGE PITS 11 Depth �Q f Sire " 2 X I Z r ? Number �- <br /> SUMPS d Distance to nearest:' Well n�jA Foundation�� Property Line �f <br /> r DISPOSAL PONDS D i ' <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 subcontracting signature <br /> I certifies the foltowing: "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 must call for ail required inspections. Complete drawing on reverse side. <br /> Signed X,_ <br /> Title: Date: <br /> ORAFI TMJ4T USE ONLY <br /> Application Accepted by Date rea <br /> Pit or Grout Inspection by -Date --- —Final Inspection b Dat <br /> Additional Comments: <br /> L t. Applicant - Return all copies to: San Joaquin County Public Health <br /> L Services, Environmental Health Permit/Services <br /> r 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH CKY RECE ED BY ATE PERMIT NO. <br /> INF <br /> . Eli 13-N IFIEV.I/M51 <br /> EH 14.24 <br />