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 /> PPZMIT 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 /> ,Toaquin County Public Health Ser ices. <br /> b <br /> L Address r �� City Lot Size/Acreage <br /> L 11..—� � r__ <br /> Owner's Name„ ddress _,., Phone <br /> &ontractor - Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well D <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well - C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C-1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy 'type of Casing Specifications <br /> I"I Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout tJl <br /> I i Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by r <br /> Repair Work Hone 0 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION R I REPAIR/ADDITION I I DESTRUCTION I (No septic system permitted if public sewer is <br /> available within 200 teet.l <br /> Installation will serve: Residence_1*1_4 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 D No. & Length of lines Total length/size <br /> FILTER BED CI Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepared this application and that the work wilt 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 cenifies 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 /> canifies 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 /> he applicant u$t call for all r quired inspections. Complete drawing on reverse side. <br /> ig,: Title: n. .M 1A Date: <br /> F EPARTMENT USE ONLY , <br /> Application Accepted by Date Area q <br /> Pit or Grout Inspection by Date Final Inspection by Date l 0 <br /> Additional Comments: <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 /> FS <br /> INFE AMOUNT DUE AMOUNT REMITTED I CASH RECEIVED BY DATE PERMFrNo. <br /> + EH 13.24{REV. In s> <br /> EH c4-2e o� , n I 7F2.3 a o � <br />