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 /> PERMIT EXPIRES 1 YEAR FROM DATE I ID <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 lith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County <br /> ^Public Health Services. <br /> Job Address L <br /> t�Zcz>,/t t' City�l.L»/A-•r<Lot Size/Acreage /rte Q,- <br /> c C t? <br /> Owner's Name �r7�v o /A4 '7tE' Address �� 6GY . 40 ��l/ht'� , Phone _ G - <br /> Contractor �,� '. .L Address ���,...1 License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Ll DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <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 <br /> n Industrial CTO pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 11 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'1 Public I1 Other Il Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation __.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth \ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION 1 I (No septic system permitted if public sewer is <br /> available within 200 feet.) C <br /> Installation will serve: Residence„4 Commercial_ Other � <br /> Number of living units: -Z— Number of(�p+,edrooms 1 C <br /> Character of soil to a depth of 3 feet: 0 �' �la:• Water table depth f4 r <br /> SEPTIC TANK ❑ Type/Mfg » t•s. . r____:... 1) T <br /> Caoacw No. Compartments <br /> PKG. TREATMENT PLT. LlMethod of Disposal <br /> r`� f� <br /> Distance to nearest: Well --t <br /> Foundation Property Line <br /> _ LEACHING LINE No. 6 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Wells Foundation s Property Line _ J <br /> C- <br /> SEEPAGE PITS 1)( DepthZ S Si:e <br /> SUMPS Ngmber <br /> r. LI Distance to nearest. Well� Foundation. 9 1ay�0 Property Line----1--k o--- '\ <br /> DISPOSAL PONDS Cl <br /> I hereby comity 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 /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature <br /> Home owner or licensed agent's signature canities the following: "I certify that in the performance of the work for which this permit is issued, 1 shall note <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 must 5iafffor all required 'nspecti s. Com eta drawing on reverse side. <br /> SignedX � Title: _( ' �� e•. . ./3-� Date: "y C/ <br /> 0 EPARTMENT USE ONLY <br /> Application Accepted by Date 'y Area <br /> /P' or Grout Inspection by Data i 'C Final Inspection bv0a�/���'�rrL� Data h.?sem/ <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services `A <br /> L >� <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 � <br /> FEE AMOVNT DDE A UNT REMITTED / <br /> INFO CASH RECEIVED BY DATE PERMIT'NO. <br /> •'M Iq_�IREV.i i.si N (. l`I� 1� i;�-oz 15z.�5 A-� y 4- I 9l—�=�1 <br />