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 /> PERMIT EXPIRES 1 YEAR FROM DA P,TED <br /> (Complete in Triplicate) <br /> Applicati s hereby a to San Joaquin County for a permit to construct and/or install the cork herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> .lob Address IL <br /> � y � City F Lot Size/Acreage <br /> t Phone <br /> Qwner's,Nama' n n ress <br /> Contrac ""JUA)��' "tor Address , License No. Phone <br /> o <br /> TYPE OF WELL/PUMP: NEW WELL ❑ - WELL REPLACEMENT P DESTRUCTION ❑ Out of Service well U <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER O 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 /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'I Public [_1 Other Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth I 1 Eastern Surface Seal Installed by. <br /> Repair'Work Done O Type of Pump H,P. State Work Done _ <br /> Well Destruction C1 Welt Diameter Sealing Material Depth <br /> Depth Filler Material 8 Depth Q <br /> C TYPE OF,SEPTIC WORK: NEW INSTALLATION I I REPAIFIADOITION_7 DESTRUCTION I I (No septic system permitted if public sewer is \ <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial OtherIlk <br /> Number of living units: Number of b rooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC-TANK 0 Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ :"; Method of Disposal <br /> Distance to nearest: Well Foundation Property Line \\ <br /> LEACHING LINE C1 No. & Length of Eines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Il Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I hive 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: "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 applic ust cat ai required inspections. Complete drawing on reverse s �] Q <br /> Signed X ' TitleDate: r <br /> OR D TMEUSF ONLY <br /> Application Accepted by - Date Ar 'f <br /> Pit or Grout Inspection by Date Final Inspection b -� ' Date <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., POw- 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOVNT REMITTED CK RECENED BY DATE PERM17'N0. <br /> INFO /I /`/ 'f�tr7� r�t7 <br /> i + EH 19.24 IREV.rim 51 // ��� /7 i J �V <br /> EH 14.26 c%J <br />