Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 11 ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HA2TLTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> RES 1 YT R FR M DAT ED <br /> (Complete in Triplicate) <br /> Application is hereby trade 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 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> City Lot Size/Acreage <br /> Job Address <br /> Phone -3 d <br /> Owner's Name zf—�y — "r-- Address <br /> Contractor <br /> Address License No. Phone <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0DESTRUCTION ❑ put of Service Well ❑ <br /> OTHER © Monitoring Well [3 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 1 <br /> SEWER LINES _�.--- DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK �. <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia, of Well Casing <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casing Specifications <br /> C1 Domestic lPrivate ❑ Gravel Pack C1 Tracy Type of Grout <br /> {•1 Public 1-1 Other n Delta Depth of Grout Seal <br /> I I Irrigation --..Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Dona Sealing Material Depth — <br /> � <br /> Well Destruction ❑ Well Diameter Filler Material Depth <br /> DepthI fl <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION 1 I afvailabPeic system within 20a feet'permitted if public sewer is V1 <br /> Installation will serve: Residence 1 Commercial_ Other 0 <br /> Number of living units: __I— Number of b rooms 0 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> IINo. Compartments <br /> SEPTIC TANK ❑ Type/Mfg i Capacity <br /> PKG. TREATMENT PLT. ❑ T_ _._ _ - Method of Disposal <br />'i Distance to nearest: Well Foundation Property Idiiine <br /> LEACHING LINE No. 8 Length of lines Total length/size <br /> 0 t Property Line <br /> FILTER BED 11 Distance to nearest: Well Foundation ��_ <br /> t <br /> j SEEPAGE PITS I�pth S Size -�Number ' <br /> :W Property Line- Foundation v <br /> SUMPS Ll Distance to nearest: Well --�-� <br /> r <br /> DISPOSAL PONDS ❑ <br /> i application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this <br /> rules and regulations of the San Joaquin county r <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 n to become subject to workman's compensation laws of California,"Contractor's hiring or sub-contracting signature <br /> certifies the following: "I cirtify that in the performance of the work for WN6 this permrt is rssuad'1 shall employ persons subject to workman's compensa <br /> tion laws of California." _ , _ —_ '+t e—, <br /> The applicant must call f e11 required ins ctions. Complete drawing on reverse side. <br /> Signed X <br /> Title: Date: 5- <br /> d�— <br /> IR DERARTMENT USE ONLY , <br /> Application Accepted by Date - Area <br /> Date ��- Final Inspection by Date <br /> Pit or Grout Inspection by <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Eaviroamental Health Permit/Services <br /> 1601 CA 95201 E. Hazelton Ave., P 0 Box 2009, Stockton, , <br /> Rt1E AMOUNT REMITTED RECEIVED 8 PATE PERMIY'N0. <br /> LASH <br /> [YOUNT <br /> . EH17.2�IREV.tiwS� O 0� 2-Jour f,f� � � L] w-/ <br /> EH 3 .28 1 r r t ` <br />