Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION r i <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-320 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> EFRUJI EXPIRES-1 YEAR FROM DATE ISSED <br /> (Complete in Triplicate) a <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 Pull Health $ervi s. s G //!l����`` <br /> I( F JLot Size/Acres e t <br /> Job Address ____ City B <br /> Owner's Name <br /> G �- Address Phone <br /> i <br /> Contractor �� Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL. REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION 'O SYSTEM REPAIR ❑ OTHER ❑ Monitoring well <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 /> n Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack, L7 Tracy Type of Casing Specifications <br /> Cl Public 1:1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Materidl S Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION III DESTRUCTION l I (No septic system permitted if public sewer is i <br /> a .,. <br /> available within 200 feet.1 <br /> Installation will serve: Res dente��Commercial_ Other <br /> \• <br /> Number of living units; � Number of bedrooms <br /> Character of soil to a depth of 3 feet: Pr �t 1A Water table depth ` <br /> SEPTIC TANK Cly Type/Mfg L C L4C re_t-e .j Capacity No. Compartments Z , <br /> PKG. TREATMENT PLT. ❑ (' / Method of Disposal <br /> Distance to nearest: Well 0 Foundation_ Property Line 2,Q!! <br /> LEACHING LINE L�"No. & Length of lines __3 L� 0 Tatfal length/size <br /> i <br /> FILTER VED ❑ Distance to nearest: Well Ll Q_ _ Foundation %L. Property Line _ <br /> SEEPAGE PITS IW'Depth �► T Size Number <br /> SUMPS Ll Distance to nearest: Well _ Foundation - T� Property Line 0 <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 County <br /> Home owner or licensed agent's signature certifies the following: "1 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 became subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies the following: "I cenify that in the rformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Ca�lif0 <br /> The ap lis (rust call a late drawing on reverse side. <br /> Signed Title: Imo' Date: <br /> R DE USE ONLY <br /> Application A epted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by 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., P 0 Box 2009, Stockton, CA 95201 <br /> FEEI AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INF <br /> . EH 241REV.r/hsl <br /> A- <br />- EH��20 <br />