Laserfiche WebLink
f - _ <br /> I APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES E F <br /> ENVIRONMENTAL HEALTH DIVISION Na, <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 N <br /> r. PEM13: �R_FS 1_YEAR _FROM DATE I S fir 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 <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address ` <br /> City Size/Acreage <br /> T ,-A—Z <br /> Owner's Name Address <br /> �. Phone <br /> -&Contractor ess iUi�� I r ' <br /> License No. Phone <br /> TYPE OF WELL/P MP: NEW WELL ❑ WELL REPLACEMENT I-) DESTRUCTION ❑ Out of Service Well 0 ` <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> t DISPOSAL FLO, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS � <br /> n industrial ❑ Open—Bottom p Manteca Dia. of Well Excavation• - s <br /> F-I Domestic/Private ❑ Gravel Pack Ll Trac Dia. of Well Casing y <br /> Y Type of Casing t <br /> l'1 Public I-) Other Specifications <br /> I C 1 Delta depth of Grout Seal Type of Grout <br /> + I Irrigation f _ Ap ox. Depth I I Eastern Surface Seat Installed by s 1 <br /> Repair Work Done 0 T - <br /> ype of p H.P. 21 Stale Work Done T <br /> Well Destruction ❑ -Well Diameter f Sealing Material`& Depth t <br /> �. <br /> Depth f Filler Material & Depth t r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION i I DESTRUCTION I No septic Sys <br /> Per it public sewer is <br /> Installation will serve: Residence Commercial ; Other available w' in 200 feet.) <br /> F <br /> Number of living units: Number of bedrooms j '• � J <br /> Character of soil to a depth of 3 feet: f I <br /> W <br /> SEPTIC TANK ❑ Type/Mfgater table depth <br /> ' r' <br /> PKG. TREATMENT PLT.❑ Capacity No. Compartments <br /> Method of Disposal <br /> Distance to.nearest: W11 F ton Property Line L <br /> 4 it �.: 1• ,-.}......� - ___ ��� <br /> LEACHING LINE 0 No. & Length' of lines � <br /> FILTER BEDTotal length/size <br /> 0 Distance to nearest: Well Foundation Property Line `r <br /> SEEPAGE PITS 11 Depth S1z@ <br /> Numb <br /> SUMPS <br /> Ll Distance to neares Well Foundation <br /> DISPOSAL PONDS p 4 - -- Props Line <br /> � 1 <br /> 1 hereby certify that I have prepared this a lication and that the work will be done in accordance with San Joaquin unty ordinances, state laws, and <br /> rules and regulations of the San Joaquin ounty <br /> ' -� r <br /> Home owner or licensed agent's signatu a certifies the following:an g: "I certify that in the per#ormance of the work for which th permit is issued, I shall not <br /> employ <br /> y 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, 1 shall employ tion laws of Californla." p y Persons subject to workman's compensa- <br /> The applicant ust f II requir in a ctions. Co Ie drawing eve a de. <br /> Signed <br /> Title: e <br /> r Date: <br /> it F. TME14T USE ONLY � <br /> Application Accepted by G>T <br /> Date—5:A�_ - Area <br /> Pit or Grout Inspection by Date <br /> I <br /> nspection by Data j <br /> Additional Comments: <br /> ,Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1.601 2. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> INFO MOUNT pUE I AMOUNT REMITTED CK <br /> CASH RECEIVED BY DATE i PERMIT•NO. <br /> i <br /> . EH d <br /> -Z�(REV,fin <br /> U <br /> EH ZI-26 <br />