Laserfiche WebLink
APPLICATION FOR PERMIT <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 /> PERMIT 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. <br /> Job Address�6 A0 ��c(�i City v' K� Lot Size/Acreage �`�'1 /��/ <br /> iCi'^ID he(/` O/r,0 1(0 ,/0e�A� Phone�f7� <br /> Owner's Name Address <br /> Contractor Address #J/A License No. OJA —Phone <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well L7 <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 O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'1 Public (.l Other (1 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 ❑ Type of Pump H.P. State Work Done _ <br /> Well Destruction O Well Diameter Sealing Material & Depth '\ <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION (No septic system permitted if public sewer is \ <br /> vailable within 200 feet.) <br /> Installation will serve: Residence.= Commercial Other <br /> Number of living units: Number of bedrooms "_�/ LA <br /> Character of soil to a depth of 3 feet: P/ l4 _Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 4 <br /> PKG. TRE TMENT PLT. ❑ Method of Disposal <br /> Distance to nearestt°?P?13u rty Line <br /> v <br /> N � <br /> LEACHING LINE ❑ No. & Length of lines ,,,� Total length/size <br /> FILTER BED + ) F) Distance to nearest: P� 1 t 6,2N&&I�rB LWitbi troperty Line <br /> SEEPAGE PITS I I Depth 441S�i�� z urpber <br /> SUMPS LI Distance to nearest: �VbIpwronME F a�o � �y�s�p�roperty Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 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." <br /> The applicant m I for re ire do omplete drawing onr arse side. <br /> Signed X Title: U/Fe Date: / <br /> F SE ONLY <br /> C� ' I <br /> Application Accepted by Date _ ` Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: _ T �� ^' �1 iii t�'- <br /> Applicant – Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. 14zelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> . EH13-24(REV.I/NS) —7 –79,v 7'r /may(. t/"• I&6 <br /> EH 14-M <br />