Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> MWIT EXPIRES X 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 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address qLn Q i1R>ALT-#L Cityr r G� Lot Size/Acreage ] <br /> Owner's Name __ Vji �Y f G Address 11; Phone <br /> Cori lractor__40-r4Le, FUAddress License No. S Phone 7 <br />- -TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out-of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL • PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> M Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing." <br /> [I Domestic/Private s Gl Gravel Pack ❑ Tracy Type of Casing Specifications.. t <br /> t <br /> I'I Public f-1 Other n Delta Depth of Grout Seal Type of Grout II <br /> J I Irrigation ­Approx. Depth I I Eastern Surface Seal Installed by i <br /> Repair Work Done; U ,Type of_Pump,_ „•„ H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material rfr Depth ; <br /> Depth Filler Material & Depth j <br /> TYPE OF SEPTIC WORK: NEW INSTAL TION I I REPAIR/ADDITION PrDESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.I <br /> Installation will serve: Residence_ Commercial— Other ..--—..•.. <br /> Number of living units: _J_ Number of bedrooms c` T <br /> Character of soil to a depth of 3 feet: ' <br /> `p/ Water table depth <br /> 8 <br /> SEPTIC TANK - Type/-Mfg• P_4-4- L;)A CC Utapacity _ No.,Compartments <br /> PKG. TREATMENT PLT. ❑% . f Method of DispPsal <br /> h . Distance to.nearest: Well!�o Foundation_LsZS _ Property Line <br /> y � <br /> LEACHING LINE ❑ No. & Length of lines- f _ Total length/size <br /> FILTER BED �n Distance to nearest:, Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS L€ Distance to nearest: Well Foundation Property Line f <br /> DISPOSAL PONDS p <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:.'l-certify that in the•perforrrmance of the work for which this permit is issued, I shall-employ persons subject-to workman's compensa- <br /> tion Isws of California." <br /> The applicant must call for all r wired inspections. Complete drawing on reverse side. <br /> Signed X Title: _ d9eyt I*�- <br /> Date: <br /> _ FOR DEPARTMENT USE ONLY <br /> Application Accepted by - Date Area 4 <br /> Pit or Grout Inspection by Date Final Inspection to Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaqin County Public Health CZ � <br /> Services' Environmental Health Permit/Servs <br /> 1601 E. Hazelton Ave., F 0 Box 2009, Stockton, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. <br /> EH 13-241AEV,riesl �0 r<— <br /> EH 14-2e `I ;� <br />