Laserfiche WebLink
3 � Lp APPLICATION FOR PERMIT <br /> � r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> REMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (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 Services. yy �E <br /> Job Address )2— E 1yt1/a I f3 e4 Lia City Lot Size/Acreage <br /> Owner's Name t:L-,a�'t'� LL: , �S `lb i✓r,q h Address �2_ �l _�- r +5 enl Cz k Phone <br /> Contractor !-f Address P Lo .Y ,�F - � 127T License No.--2 7q-3c`5.3 Phone -,-.7 zz <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT F DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATIONS SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well [7 <br /> DISTANCE TO NEAREST: SEPTIC TANK /`> r SEWER LINES DISPOSAL FLD. PROP. LINE /fid , <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f� Industrial 14 Open Bottom ❑ Manteca Dia. of Well Excavation % Dia, of Well Casing <br /> Xbomestic/Private CI Gravel Pack ❑ Tracy Type of Casing 5�(t'e`-� Specifications <br /> I'1 Public I_) Other F1 Delta Depth of Grout Seal _ Type of Grou1J:1f,'k �t <br /> I I Irrigation G_-)% Approx. Depth /1 1 Eastern Surface Seal Installed by fr? n r <br /> Repair Work Done 11 Type of Pump rill _ H.P. _1 � State Work Done <br /> Well Destruction ❑ Well Diameter _ Sealing Material 6 Depth <br /> Depth Filler Material b Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION { I (No 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. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation _ Property Line <br /> LEACHING LINE L) No. & Length of lines Total length/size <br /> FILTER BED C] Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I1 Depth _Size _ Number <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS L7 <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 signatur�fZ <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- J <br /> tion laws of California." <br /> The applicant must call for all required inspections, Complete drawing on reverse side. <br /> Signed %1 / i Jit rd/�i.L�l E1 f Title: Date: <br /> ZZ(I <br /> _ ' DEPARTMENT USE ONLY <br /> Application Accepted by Date . <br /> r Area <br /> Pit or Grout Inspection by pate - Final Inspection by i ! ' Data <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, hYsvironmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK a RECEIVED BY DATE PERMIT'NO. II ) <br /> r EH 13.24 IREY.1/n 51 1 ✓ jj/'�� u' �� rte-/ <br /> EH'*2e <br />