Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> RES 1 YEAR FROM DAIR J§SUED <br /> (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the vork 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 /> Job Address - -go- 'O ��Ca� S� Acity �� -Lot Size/Acreage <br /> Owner's Name-&Pra4NJ Address Kam Phone l <br /> ,i <br /> Contraclor Address/TJ� L �t�!'1 License No. w& Phone'22!?—!;W <br /> TYPE OF WELL/PUMP: NEW WELL 13WELL REPLACEMENT 1-7DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP IN ❑ SYSTEM REPAIR L7 OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> r <br /> to Domestic/Private 0 Gravel Pack. El Tracy Type of Casing Specifications <br /> ('I Public L-1 Other rl Delta Depth of Grout Seal Type of Grout <br /> I 1 Irrigation Approx. De th I 1 Eastern uri Sem Installed by �,fy <br /> Repair Work Done aee of Pump � <br /> Y e _ H.P. _ _ ____ State Work Done Mk4lt, gxnp <br /> Well Destruction 0 Well Diameter Sealing Material & Depth 1 <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC.WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet,) ;�1 <br /> Installation will server Residence Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth �tpA� <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments �1 <br /> PKG. TREATMENT PLT. ❑ Method Disposal l <br /> Distance to nearest: Well Foundation PropertA�w LEACHING LINE 0 No. & Length of lines Total length/si <br /> FILTER BED 1-1 Distance to nearest: Well Foundation Property Line j _1(]p�f <br /> l UU 992 <br /> SEEPAGE PITS It Depth Sire Number FNVIRONMENTAI. HEALTH <br /> SUMPS LI Distance to nearest: Well Foundation Property LPE�€RVICES <br /> DISPOSAL PONDS 17 <br /> I hereby certify that I have prepared this applicatio and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulation of the San Joaquin Count <br /> Home owner or 'c sed agent's signature cerci s the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any per in such nner as to beco a ubject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the fol ing: "1 c rtif that in the pe or once of the work for whit this parmit is issued, I sol employ persons subject to workman's compensa- <br /> tion laws of I'ornia.' <br /> The ap lica st call o I omplete drawing on eve side. <br /> Signed Title: Date: r <br /> FOR DEPARTMENT USE ONL Q <br /> Application Accepted by Date 7 -- .Area �! <br /> Pit or Grout Inspection by Date Final Inspection by Date�Z <br /> Additional Comments: <br /> -t <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 /> FEE <br /> INFO AMOUNT DUE? AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> .Xi'. EH 1321(REV.v/H 50 IF .. <br /> EN 1126 �V J t? c7 T 2 <br /> t <br />