Laserfiche WebLink
APPLICATION FOR PERMIT <br /> 3 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468--3420 <br /> P O BOX 2009, STOCKTON, CA 95201 C� <br /> PERMIT EXPIRES 1_YEAR rRO11 DATE ISSUJP <br /> 1 (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 4:1th San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. � <br /> �j 1 / <br /> Job Address ✓ r City lot Size/Acreage <br /> ��}} -•� .�` /� J '] �,p ��'�9 �, 737 <br /> Owner's Name <br /> dJ� ! l r !J i "l_ Address l ! gS �[rJl_- y'2�ne� �''tt/ : <br /> Contras to Address ` { E, <br /> L 4 -License No. r6��tPhone IN <br /> -TYPE OF WELL/PGA P: I NEW WELL ❑ WELL REPLACE ENT ❑ DESTRUCTION AOut of Service Well ❑ <br /> BUMP INSTALLATION C] SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION. AGRICULTURE WELL OTHER WELL PITS/SUMPS i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> t.7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'l Public 1-1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —,.Approx. Depth I I Eastern Surface Soul Installed by V� <br /> Repair Work Done 0 Type of Pump,° H.P. State Work Done T <br /> Well Destruction ❑ Well Diameter ° Sealing Material & ,Depth <br /> Depth 4. Filler Material & Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/AD ITION I 1 DESTRUC ON l 1 (No septic system permitted if public sewer is <br /> i 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 <br /> SEPTIC TANK. ❑ Type/Mfg t Aoun <br /> acity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal t <br /> Distance to nearest: Well onProperty Line p <br /> LEACHING LINE Ll No. & Length of lines Total length/size <br /> 4 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Wel 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 certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall n <br /> employ any person in such manner as to become subject to workman's compensation taws of California." Contractor's hiring or subcontracting 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 appli t m st ca for a r uired in plate drawing on reverse side. <br /> n <br /> Signed Title: rf'L/��'�l T�(_1-° _._ Date: �r <br /> r f <br /> 1 DEPARTMENT USE ONLY . <br /> Application Accepted by,.—4II Date �^ Area �~ <br /> Pit or Grout Inspection by I Date Final Inspection by � Q Date�%2 <br /> t <br /> Additional Comments: <br /> Applicant Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> li6oi E. Razelton Ave., P-0 Box 2009, Stockton, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE I AMOUNT REMITTED CASH Ck if RECEIVED BY DATE{�y� PERMIT'NO. <br /> . EH 13.21 tREv.1/x 51 �� r /� I-7D G <br /> EH 14-29 V -V L• <br />