Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN J-OAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTHDIVISION <br /> PHONE (209)468-3420 <br /> P 0 BOR 2009, STOCKTON, CA 9520x2 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. / f / /, <br /> Job Address �`�O,- /Z tel`,F -SIOA J 4 & City Lot Size/Acreage <br /> .y <br /> Owner's Nam�SCA 62/4 GT fu�/�i "�c°��Address6SS �i C.l�s !ooi/��'✓Gr� Phor, <br /> Contractor ess a~'aLiccense G�Sr�s'`SSS�9Phon F p <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION Ll Out of Service Well 0 <br /> PUMP INSTALLATION O SYSTEM REPAIR Ll OTHER O 3 Monitoring Wellg <br /> Lie <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> I ENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Al <br /> 0-0 <br /> (_ Industrial O OravBottom O Manteca Dia, of Well Excavation T Dia. of Well Casing <br /> [.] Domestic/Private Gel Pack O Tracy Type of CasingStggd" yn /dVG Specifications <br /> I'1 Public 1.1 Other n Delta Depth of Grout Seal 4 Type of Grou 1;A_ <br /> 1 1 Irrigation 5�t.Approx. Depth I I Eastern Surface Seal Installed by Ides Ji"' <br /> Repair Work Done U Type of Pump _ A H.P. N,4 State Work Done <br /> Well Destruction O Well Diameter NA Sealing Material & Depth AM <br /> Depth AJ A Filler Material & Depth N A <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.) <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 /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED C] Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size _ Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that 1 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 is d, I shall employ persons subject to workman's compensa- <br /> tion laws of a�2 nie.1 ' <br /> The applicaallre uire 'ns tions. Complete drawing on rev side. l��> l Q <br /> Signed X Title: te: 1 1 <br /> FOR DEPARTMENT SE ONLY 6 <br /> Application Accepted by Date Q Area _ <br /> Pit or Grout Inspection by Date Final Inspection by Date 30 a <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 /> I <br /> EH;1-?d I /FEE AMOUNT DUE 1 AMOUNT REMITTED CK RE I ED BY DATE /PERMIT NO. <br /> . EH 13.21IREV.t/n5) � 251 g ho qu-sm- <br />