Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PFAMIT EXPIRES 1 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 Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address City Lot Size/Acreage ' <br /> Owner's Name t; Phone u <br /> Contractor ddress icense No Phone f/ <br /> TYPE OF WE LIP MP: NEW ELL ❑ WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION- ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 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 Q Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack C Tracy Type of Casing Specifications <br /> I'l Public Cl Other f1 Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation ___._Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done L7 Type of Pump H.P. State Work Done ,! <br /> Well Destruction ❑ Well Diameter Sealing Material & D th f <br /> Depth Filler Material pth Q <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION I DESTRUCTION I 1 lNo septic system permitted if public sewer is oQ <br /> available within 200 feet.) <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 r <br /> SEPTIC: TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines611, 7 Total length/size <br /> FILTER BED ❑ Distance to nearest: Well "Z'2_ Foundation ag:�2 Property Line <br /> EPAGE P j I, depth size '' Number <br /> Sum—Ps Ll Distance to nearest: Well Foundation � Property Line <br /> DISPOSAL 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, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature cenifies 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 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 California." <br /> The applicant st fQL41 r quire s ctions. trwing on rover side. <br /> Signed itle: t.(�n. _ Date: <br /> E�,-73 A�,"/?- <br /> P U_SE ONLY <br /> Application Accepted by Data �� 0 Aro, <br /> Pit or Grout Inspection by Date Final Inspection byDate l f <br /> Additional Comments: <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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> . EN 13-24 ftV.i r n 5 i ° <br /> EH 14.26 170,off ` L--3i 2 o 9 2—I -43 <br />