Laserfiche WebLink
APPLICATION FOR PERMIT <br /> S JOAQUIN COUNTY PUBLIC HEALTH SERVICE <br /> ENVIRONMENTAL HEALTH DIVISION ► <br /> 1601 E. B2 ,V (209)468-34 <br /> pOOX 009STOCKTON, CA 95201 <br /> RTs5 1 YEAR FR D T <br /> (Complete in Triplicate) <br /> Application is hereby made to Sari 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 1662 and the Rules and Regulations of San <br /> Joaquin Colony Public Health Services. <br /> O �Q ,9 �a� Lot Size/Acreage <br /> /V City <br /> Job Address t4 <br /> � - i✓ID Phone <br /> I Address <br /> Owner's Name _ f, ! .�f r <br /> ' I-I,�U(Z�l�� �License No. a Phone <br /> ��- fl�.� Address <br /> l Contfactor �— WELL flEPLACEMENT Ll DESTRUCTION 0 out of Service Well ❑ <br /> 7YPE"OF.WELL/PUMP: <br /> NEW WELL ❑ OTHER ❑ Monitoring Wall <br /> cl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> SEWER LINES J.. DISPOSAL FLD, PROP. LINE <br /> AISTANCE^TO NEAREST; SEPTIC TANK OTHER WELL PITS/SUMPS ' <br /> FOUNDATION _ �--- AGRICULTURE WELL <br /> x � <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS .- Dia. Well Casing <br /> C] Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Cl Industrial Specifications ; <br /> Type of Casing <br /> [7 Domestic lPrivate El Gravel Pack ❑ Tracy Depth of Grout Seal TM Type of Grout r <br /> I'I Public FI-I Other, n Delta - _ `. " - - _r <br /> Approxi Depth 1 I Eastern Suridce Seul Installed by <br /> I i irrigation State Work Done _ <br /> Repair Work Done ❑ Type of Pump � H.P. r v <br /> m— Sealing Material & Depth <br /> Well Destruction�❑ Well Diameter <br /> j 1 Filler Material & Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIRIADDiTION•1 1=�DESTRUC7l0'N I I availabletwthin 200 feetstem !) <br /> dance <br /> if public sewer is ` <br /> ! <br /> Installation will serve:�AasidanceZCommercial— Ot'i6r� -� <br /> F Number of living units: � Number of bedrooms <br /> / water table depth; <br /> Character of soil to a dept f 3 feet: - -^-•�No. Compartments <br /> SEPTIC TANK Type/Mfg <br /> Capacity-" <br /> `�'• I � � Method ofDisposal <br /> PKG. TREATMENT!PLT:❑----"-"�,"�° y '�.�/� f <br /> S 8 Foundation ���� Property Line <br /> Distance to nearest: Well ,- -. <br /> i I Tbtal length/size <br /> LEACHING LINE No. & Length of tines <br /> e �-ei►1.f�.� ._: <br /> ! Foundation �-- Property Line <br /> FILTER BED 0 Distance to nearest: Well <br /> Number t <br /> SEEPAGE PITS 1 1 Depth - Size .. <br /> Foundation Properfy.;Line <br /> SUMPS LI D-istantie to nearest: Well <br /> i DISPOSAL PONDS ❑ <br /> I <br /> I hereby certifythat I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an <br /> i rules and regulations of the San Joaquin County <br /> Home owner or licensad 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 /> ompen <br /> f " <br /> workman's c ipermit vfContractor's hiring r1etbjsct to warkman5ampensa <br /> signature <br /> py any person <br /> rsoinsulhmof he wok far which this is issed, I shall employpersonssu <br /> certifies the o i that in rthe Performancto become e <br /> tion laws of California. Q <br /> The applicant must call for quired ins cti , S. Complete drawing on r arse side. <br /> i` <br /> Title: Date: <br /> Signed <br /> 0_ FOR DEPARTMENT USE ONLY <br /> 1.� Date �Z' r � Area _��----- <br /> Application Accepted by 4c7 -7?- <br /> Final Inspection by Date <br /> Pit or Grout Inspection by Date --- 1 <br /> � d <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health krlw <br /> + Services, Environmental Health Permit/Services CA 95201 �^--�—� <br /> i 1601 E. Hazelton Ave., F 0 Box 2009, Stockton, �y <br /> =CKRECEIVED DATE PERMIT'NO. <br /> IFEE N0 AMOUNT DUE AMOE <br /> MITTER �^� ` &S <br /> � <br /> EH 13-24 iREV.1�rs 51 <br /> �,<3 V� -a-1-90 U 1r0 <br /> EH 74.26 <br />