Laserfiche WebLink
APPLICATION FOR PERMIT 7 _� <br /> SAN dOAQUIN COUNTY�LIC HEALTH SERVICES <br /> I� <br /> / F• ".� ENVIRONMENTALaA`,T2 IVISION <br /> 1601 E. HAZELTON AVE. , - (209)46$-3420 <br /> P 0 BOX 2009, STOCR1iyN, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ED <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 I <br /> application is made in compliance with San Joaquin Cgunty 0 Ainancee No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. Q �� - ����� �� <br /> 9H3 - 3`7 ( Q • City Lot Size/Acreage <br /> Job Address <br /> i�f.(.fr'i /7 !� Address Phone u '� <br /> Owner's Name -�^ D <br /> Contractor <br /> 114 <br /> License No. Z l6 Phone 6 �� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ i <br /> Monitoring Well11 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑PROP. LINE/� � ,e.G4 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. <br /> FOUNDATION AGRICULTURE WELL _7100 I OTHER WELL PITS/SUMPSLLO <br /> f I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS — <br /> C1 Industrial CJ Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [I DomesticlPrivate ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> F1 Public I:1 Other Cl Datta Depth of Grout Seal ID-L4n Type of Grout <br /> I I I Irrigation — Approx. Depth I I Eastern Surface Saul Installed by <br /> Repair Work done LJ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Depth <br /> Filler Material & Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION I I Mo 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 <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 /> I <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> i f�' <br /> FILTER BED L) Distance to nearest: Well Foundation Property Line [/3 <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> -61 PONDS ❑ <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, andi� <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, I shall employ persons subject to workman's compensa- <br /> tion laws of Calif <br /> The applicant ust II for all required intpec' ns. Complete drawing on reverse side. /] <br /> ZI <br /> Signed Title: /"/fir- ---- Date: v i <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by Date fee <br /> Pit or Grout Inspection by Date Final Inspection by Datt� <br /> Additional Comments: <br /> Applicant — Return all copies to: San Joaquin County Public Health <br /> Services, iavironmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTEDRECEIVED BY DATE PERMIT N0. <br /> t{ INFO CASH <br /> F • EH 13-24(REV.I I M 5) 1 � <br /> EH 74.2e 9�p <br />