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 /> t <br /> P O BOX 2009, STOCKTON, 'CA 95201 ° <br /> PFJWIT EXPIRES 1 YEAR FRQM_DATE ISSUED t <br /> (Complete i.i Triplicate) <br /> Application is hereby made.to San Joaquin County for a permit to construct and/o"r 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 /> /63 G �C��- f�/t <br /> Job Address �- -_ City [VrD ' Lot Size/Acreage <br /> Owner's Name ���N AA--- Address sxm Phone <br /> Contractor SJ Address 6110)Z __ License N37731Z Phone33Jr <br /> TYPE OF WELL/PUMP: NEW WELL J! WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well. 0 j <br /> PUMP INSTALLATION SYSTEM REPAIR El OTHER C Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK LED SEWER LINES DISPOSAL FID.! PROP. LINE 22- <br /> FOUNDATION <br /> 2 FOUNDATION AGRICULTURE WELL OTHER WELL. 'y PITS/SUMPS �. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPEC IFICATIONSm/\ - [ _ <br /> Cl 0 Open Bottom 0 Manteca Dia. of Well Excavatio�4r Z Q Dia. of Well Casing <br /> omestic/Private Gravel Pack 0 Tracy Type of Casing - Specifications-' <br /> i'I Public t-1 Other ❑ Delta Depth of Grout S1 I .roc' Type of Grout. <br /> I i Irrigation Approx. Depth I I Eastern Surface Seal Installed / JN QAC Repair Work Done 0 Type of Pump - H.P. _ !State Work Done <br /> Well Destruction O Well Diameter Sealing Material & Depth l <br /> Depth Filler Material & Depth/ <br /> t I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> f available within 200 feet.) 0.01 <br /> installation will serve: Residence_ Commercial— Other " I <br /> Number of living units: Number of bedrooms f . <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, 0 1 Method'of Disposal. <br /> Distance to nearest: Well Foundation Property Line -'.00, <br /> t r <br /> LEACHING LINE 0 No. & Length of lines __ - �4 �-1 s Total length/size <br /> FILTER BED 0 Distance to nearest: WeII Foundation Property line <br /> SEEPAGE PITS 11 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 I - <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 workmen'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 /> mus � /��� <br /> The applicant Z�J� all required ins coons. Complete drawing on reverse gide.. _ • . 4 <br /> Signed X � � Cf/it'y T a--- Title:: L7"�-tri _ . Date: <br /> OR DEPARTf1AEN IJISE,ONLY.4�M <br /> Application Accepted by l Date '' Area <br /> Pit or ro Inspection by� at Final Inspection by: S&j a <br /> Im <br /> I� <br /> Additional Comments: <br /> A <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., F 0 Box 2009, Stockton, CA 95201 <br /> FEE <br /> INFO AMOUNT DILE AMOUNT REMITTED CASH CK RECEIVED BY PATE PERM11'NO, <br /> ( f <br /> iEHI`.224e1REV.rrnSr � JT. �� �� tYY � _ 1 <br />