Laserfiche WebLink
►.` APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 T. HAZELTON AVE. , PHONE (209)46$-3420 <br /> P O BOR 2009, STOCKTON, CA 95201 <br /> PFJWIT %FIRES 1 YEAR EROW DA ED <br /> f (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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Servi.ces. # <br /> +1 q I ` Lot Size/Acreage „7 <br /> Job Address ��r City <br /> ST,r� /1 1 I Address �L Phone <br /> Owner's llama r <br /> Gl /IHSS Address� tw- License No. 2, 3S5 phone 3 y�y7 L <br /> Contracto -- <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT C_1 DESTRUCTION ❑ Out of Service Well 0 <br /> r Q <br /> PUMP INSTACLATIONSYSTEM REPAIR ❑r _yam, <br /> ' TMEfi._❑ Monitoring Well <br /> � C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL_ -- --OTHER WELL.— PITSdSUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C] Industrial ❑ Open Bottom [O Manteca "'" Dia-of Well-Excavation Dia. of Well Casing <br /> c =,f T` e of Casing ' p� -� —Specifications-. <br /> �-VDomestic/Private Gravel Pack E-7 Tracy Yp � 9 ._ <br /> I1 Public i-1 Other F1 Delta Depth'of Grout S I A Type of Grout <br /> I Irrigation L4'�Approx.,Depth I i Eastern Surface Seal Installed by t-0- j <br /> Repair Work Dane ' 0/Type of Pump ___S(1 16— H.P. 3 'State Work Done <br /> �? Sealing Material & Depth <br /> Well Dest►uction .❑ Well Diameter <br /> IDepth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I ffVa septic system permitted if public sewer is a <br /> I available within 200 feet.) <br /> Installation will serve: Residence—4 Commercial_ Other \ <br /> Number o04ving units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: + !!L_Water;able depth <br /> SEPTIC TANK•. r d Type/Mfg Capacity? No. Compartments <br /> PKG. TREATMENT PLT.❑ <br /> Method of Disposal <br /> ' Distance to nearest: Well Foundation ' Property Line <br /> �1 I <br /> LEACHING LINE L-1 No. & Length of lines -;Total length/size <br /> a <br /> FILTER BED_"' ) ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE-PITS f s 1 1 Depth ' Size Number <br /> SUMPS LI 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 I County <br /> Home owner or licensed agent's signature cenifies 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 applicant _usPcl ll f r all r quired inspections. Complete drawing on reverse side. <br /> Signed X } Title: 42LAE1, Date: <br /> . �� FOR PARTMENT�USENLY-.•. .--- <br /> Application Accepted by Date Area <br /> Pit or ro" Inspection by Date Final Inspection by Date , <br /> rz �. <br /> Additional Comments: ! f <br /> Applicant ^ Return all copies to,. San Joaquin County Public Health �rrtf� <br /> 3 Services, Environmental Health Permit/Services <br /> 1601 E. Razelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTEDCASH 'RECEIVED BY DATE , PERMIT NO. <br /> INfO � <br /> r EH 24 1REV.I 51 3 <br /> EN 3 <br />