Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HA2ELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 . <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISS11ED <br /> (Complete in Triplicate) <br /> I <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This I <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. C f -e <br /> ``� rr i Cit �j 4- Lot Size/Acreage <br /> Job Address Y i <br /> Owner's Name R roo S Address IZ�v Phone <br /> r � C ' <br /> Contractor �' P,�dI't R e,ed 90<3d License No. :3 Phone I ,0. d <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ❑ . <br /> PUMP INSTALLATION 10 f SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 0 <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 Hyl <br /> L-1 Industrial Cl Open Bottom ❑ Manteca Dia. of Well Excavation f Dia. of Well Casing <br /> TA Domestic/Private X Gravel Pack L7 Tracy Type of Casing Specifications If r/ <br /> F] Public 1a Opwr (71 Delta Depth of Grout Seal 1� Type of Grout t' 1 [r+' <br /> I I Irrigation Approx, Depth I ) Eastern Surface S I Installed by rl�1�T1t-�� <br /> Repair Work Done 0 Type of Pump H,P. A� State-Work Dona <br /> Well Destruction O Well Diameter Sealing Material & Depth_, <br /> Depth "" "' ''Fille Matez4al`&`Depth S <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I• REPAIR/ADDITION f I DESTRUCTION I 1 (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial'_..;'•.'Other ry ' <br /> Number of living units: Number of bedrooms. <br /> Character of soil to a depth of 3 feel: Water table depot <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 Cl No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line I <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll 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:-'A 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 h0ind-&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 or all req uir d inspectio s. Complete dra ing on reverse side. r f <br /> Signed X itle: ._. ?1 Date: <br /> F DEPARTMENT USE ONLY ; <br /> Application Accepted by Date H279 Area <br /> r <br /> Pit or out Inspection b Date Final Inspection by Dat <br /> Additional Comments: A,/_ <br /> � <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 /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASA RECEIVED BY DATE ?ERM17'N0. <br /> + 2J 1-9 <br /> tEH 13- `— f <br />