Laserfiche WebLink
S < <br /> g : y APPLICATION FOR PERMIT s. <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSPED <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 /> 1 application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County PublicHealthServices. <br /> Job Address `'' Q ` �CSty Lot Size/Acreap�e, <br /> Owner's Namele �-e1L1 Address Phone <br /> L_fJ <br /> Contractor VLZ Address C �" License No. Phon <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL.REPL CEMENT,❑_...,- DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ � SYSTEM REPAIR C7 OTHER ❑ Monitoring Well G <br /> DISTANCE TO NEAREST: SEPTIC TANK ,SEWER LINES-` DISPOSAL FLD. PROP. LINE ' <br /> FOUNDATION '`AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ` o. ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [:l Domestic/Private Gl Gravel Pack C� Tracy Type of Casing Specifications <br /> I'1 Public t.l Other 171 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx.bepth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done n <br /> _ Well Destruction ❑ Well Diameter <br /> Sealing Material & Depth <br /> "Depth Filler Material & Depth S ` <br /> TYPE OF.SEPTIC WORK: NEW INSTALLATION ( I REPAIRIADDITION DESTRUCTION t I 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: t Numberof 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 r� <br /> Distance to nearest: `Well Foundation Property Line <br /> a'* LEACHING LINE , <br /> r. 0 No. $.Length of lines Total lengthlsize <br /> «; r ���� � <br /> FILTER 8 _ED �❑" Distance to nearest:. well Foundation- ��--- PropertyrLine,,/Q9 <br /> SEEPAGE PITS 11 Depth Size�T Number <br /> SUMPS LI Distance to nearest: Well Foundation_ Property Line <br /> Line <br /> DISPOSAL PONDS ❑ ` w- '"r� <br /> I hereby certify that I have prepared this application and that the wor wilt b 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: "t 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 became subject to workman's compensation taws 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 must 11 fo all requi dins tions omplete drawing on reverse side. <br /> Sr � <br /> Signed X Date: � <br /> FOR DEPARTMENT USE ONLY <br /> Applica ' n Accepted by Date Area .r <br /> P' rout p ion by I Dat Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 2:601 E. Razelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY GATE PERM17 N0. <br /> IWO 1 ,�y! I CASH (� I -71 <br /> , EH13-24IREV.tiHei. �' l � { L +� S [ '1a <br /> EH 1126 <br />