Laserfiche WebLink
APPLICATION FOR PERMIT s,� C7` <br /> F <br /> E <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION S E P 9992 <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 ��$�OI��II��VTi�L HEALTH <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT/SERVICES <br /> IPERMITEXPIRES 1 YEAR R�ATE �_ <br /> f (Complete in Triplicate) <br /> 4 Application is hereby made to Ban Joaquin County for a permit to construct and/or install the work herein described. This <br /> E 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. �r <br /> 9'7 <br /> I� <br /> Job Address CityA266424, ot Size/Acreage <br /> Owner's Name ? ddress Phone 3 <br /> f <br /> Contractors Address #Se N Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL. REPLACEMENT M DESTRUCTION o 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 I PITS/SUMPS { <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> l=1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casingi(b <br /> - ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> l`l Public C7 Other ?� Cl Delta Depth of Grout Seal Type of Grout <br /> I 1 Irrigation ___.Appro Depth I I Eastern rfaee Seat Installed by <br /> Repair,Work Done Type of Pump H.P. State Work Dane <br /> Welt Destruction El Well Diameter Sealing Material A Depth <br /> Depth Filler Materiel 6 Depth i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION 1.4 DESTRUCTION I I iNo septic system permitted it 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. TREATMENT PLT. 0 — Method of Disposal <br /> Distance to nearest: k'.Well Foundation Property Line <br /> tI a. <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED EI Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth `'j Size Number <br /> C SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Cl i1 <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.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 t+a performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Calif nia." !f <br /> The applicant u teff o all r red:in ction Campl drawing on rpr,, ida. <br /> r <br /> Signed X Title: Date: <br /> R DEP TM LY_ <br /> Application Accepted by Date <br /> Pit or Grout Inspection by Date Final Inspection <br /> Additional Comments: <br /> e <br /> Applicant — Return all copies to: San Joaquin County Public Health <br /> i.-. Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave.. P 009, Stockton, CA 95201 <br /> FEE AMOUNT DUE 3 AMOUNT REMITTED CK RECEIVED BY YATE PERM17'NO. <br /> k `NF 9 <br /> a EH 13.24[REv,tIA51 <br /> EH 11-2e <br /> { <br />