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 BOR 2009, STOCKTON, CA 95201 <br /> PERMIX EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete is 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 /> r� <br /> .1 2t <br /> Job Address �f�n[���' — City i ` Lot same/Acreage <br /> Owner's Name Add�eSsr Phone <br /> Contractor- AL &f(,Lj� t Address ___ License No. 7 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR © OTHER O - Monitoring Well C <br /> 1 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 /> Cl Industrial ` ❑ open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [I Domestic/Private Ll Gravel Pack ❑ Tracy Type of Casing Specifications.- -- <br /> CI Public 1-1 Other n Delta Depth of Grout Sea] Type of Grout V" <br /> I Irrigation Approx. Depth I I Eastern Surface Seal Installed by l! <br /> Repair Work Done 0 Type of Pump H.P. State Work Done r <br /> Well Destruction ❑i Well Diameter sealing Material & Depth (fu <br /> Depth Biller Material & D pth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION { I (No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve:-Residence - Commercial - Other <br /> Number of living units: __L._ Number of drooms, <br /> Character of soil to a de-pthh f 3 feet: ' Water table depth <br /> SEPTIC TANK TX Type/Mfg L Capacity No, Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Dispysal <br /> Distance to nearest: Well FoundationQ J� _ Property Line —5C <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation., Property Line <br /> SEEPAGE PITS y I I, Depth -Size _ Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <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: "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 workma 's compensa- <br /> tion laws of California." <br /> The applicant mtr¢t call for all req 'red inspections. Complete drawing on reverse siide. <br /> Signed X Title: hT h�12� - Date: <br /> FO PART NT USE ONLY <br /> Application Accepted by Date Area <br /> E ? <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, Eaviro=entalL Health Permit/Services <br /> I 1601 E. Hazelton Ave.."-,P 0 Box 2009, Stockton, CA 95201 <br /> FEE MOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMI7'NO. <br /> INFO CASH <br /> . EH 13.24 IREV.ri x s) <br /> 1:H i4-25 - <br />