Laserfiche WebLink
APPLICATION FOR PERMIT <br /> b <br /> � • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION " <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420f <br /> P O BOR 2009, STOCKTON, CA 95201 ` # <br /> EXPIRES 1 YEAR FROM DATE ED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work here-in 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 /> Job Addresszzh <br /> City Lot Size/Acreage <br /> Owner's Name & 92A r`�,(� Address _ Phone / ✓'� <br /> Contractor FI vS Address License No. Phone <br /> TYPE OF WELL/PUMP: NM WELL WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ <br /> .g \ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ iWoz— HER ❑ Monitor Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -�""� <br /> IS; <br /> FLUr.-"y�_ PROP. LINE <br /> / OUNDATION AGRICULTURE WELL-�� THER WELLt a PITS/SUMPS/Zo <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> M industrial O Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing <br /> Domestic/Private f i'Gravel Pack 0 Tracy Type of Casing _ Specifications � <br /> I'1 Public �L1 Other l n Delta Depth of Grout Seal Type of Grout <br /> --7 <br /> I i irrigation - ;crS 0 Approx. Depth I I Eastern urface Seal Installed by <br /> Repair Work Done 0 -Type of Pump �� H.P. -7— State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> 0 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIRIADDITION l I DESTRUCTION I k lNo septic system permitted if public sewer is <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 <br /> SEPTIC TANK: ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREAT16ENT PLT. 0 ' r! Method of Disposal <br /> �f y� Distance to nearest: Well Foundation ,Property Line l <br /> LEACHING LINE Cl ` No. & Length of lines Total length/size <br /> FILTER;BED n Distance to nearest:' r Well Foundation Property Line <br /> 't ' <br /> SEEPAGE,PITS 1 I I ._Depth Size _ __ _ Number <br /> SUMPS CI Distance to nearest: Well ~ Foundation' Property Line <br /> i <br /> DISPOSAL'PONDS ❑ ` <br /> I hereby certify that I have prepared this applicationand that the work will be done iA accordance with San Joaquin county ordinances, state taws, and <br /> rules and regulations of the San Joaquin. County- ky - x P <br /> Home owner or licensed agent's signature cehifies 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 Eo,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." j <br /> The applica mu all I quire ti Complete drawin0 on revs s de. <br /> sig <br /> Signed X ' le: f �- Date: <br /> TO DEPARTMENT USE-ONLY/ <br /> Application Accepted by Date 171�� 1 -_. Area <br /> Pit or Grout Inspection by m1e, v 2�. 03inal.Inspection by. Date <br /> y Additional Comments: "� 12 ` �"` I Ls <br /> Applicant - Return all copies to: San Joaquin County Public ealth G rb,� V4 tx r N �� <br /> Services, Environmental Health Permit/Services �ulG —ee <br /> F 0 Boxy 2009, Stockton, CA 95201 <br /> t .1601E. Hazelton Ave., <br /> AMOUNT.-DUE i'AMOUNT REMITTED " CASH kECEIVED BY DATE PERMIT'NO. <br /> k . EN 13-24(REV.t i n 5) f 13 ` ' J 4 y -90 - r_ <br /> EH 14-26 111 �J <br />