Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION R E Co Em I VF <br /> 1601 E. HAZELTON AVE. , PHONE (209)468--3420 AUG 2 9gnro <br /> P 0 BOX 2009, STOCKTON, CA 95201 wo <br /> ENVIRONMENTAL HFALTH <br /> PMIT EXPIRES 1 YEAR FROM DATE ISSUED PER PriIT/`�'�:�;'>rGCES <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 compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address `J- � _ _� __- 1a/J - L Cit Lot Size/Acreage <br /> Owner's Name '` _( Addres, __ __ Phone <br /> Conlracto �ddesP_4:; l License No f_ /� Phon& l <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATIONSYSTEM REPAID 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 <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> tic/Private ❑ Gravel Pack El Tracy Type of Casing Specifications <br /> l'1 Public 1-1 Other n Delta Depth of Grout Seal Type of Grout <br /> 1 I Irrigation Approx. Dept h 1 Eastern , urface Seal Installed liy <br /> Repair Work Done Type of Pump H,Pk V State Work Dona Y <br /> Weil Destruction ❑ Well Diameter Sealing Material is Depth <br /> Depth Filler Material & Depth F <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I (No 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 F <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 /> LEACHING LINE C1 No. & Length_of lines. r Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation t Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Cl % <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,A.shall employ persona subject to workman's compensa- <br /> tion laws of Californja." , <br /> The applicant s call for inspections. Complete drawing on re er a sida— <br /> d <br /> Sign d Ti Date: d 7 tJ <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by ' Date 7_�o Id Area 1r <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services �nfv <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. <br /> + EH 13-24 IREV.I/n 51 Igo <br /> EH 1.4-2631 �1 a � <br />