Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION r <br /> 1601 E. HAZELTON AVE. , PHONE (209)468--3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> P MIT BXP RHS_ 1 YEAR FROG DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the workphereiae-pt-neapplication is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulao an <br /> Joaquin County Public Health Services. <br /> � ` 1 Y <br /> r , Lot Site/Acreage <br /> Job Address City <br /> 12�7 <br /> Owner's Name r` a_,, G4 Address 4q!?" &d Ir IGS Phon C Gt LI <br /> Contractor - oma- �� AddresscP 6 -�z. � ' <br /> License No. ra �-,�]� Phon <br /> TYPE OF WELL/PUMP: NEW WELL WELL REIPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C1 OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESl Q r DISPOSAL FLD, PROP- LINE, <br /> FOUNDATION / AGRICULTURE "� <br /> WELL �_ OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> rl M <br /> 0 Industrial Cl Open Bottom" 0 Manteca Dia. of Well Excavati Dia. of Well Casing �1 <br /> r <br /> (Oomestic/Private D(Gravel Pack 0 Tracy Type of Casing � Specifications <br /> H Public la Other n Delta Depth of Grout Seal Type of Grout= ,,zi <br /> I I IrrigationT —.Approx. Depth I I Eastern Surface Seal installed by ��� <br /> Repair Work Done 0 Type of Pump H,P. State Work Done r <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth t l <br /> Depth Filler Material & Depth <br /> TYPE OF-SEPTIC WORK:.-NEW INSTALJ T40N-N--AE-PAIRaADDITION ( I DESTRUCTION 11 -INo septic-sys(em permitted if public sewer is <br /> available within 200 feet.) S <br /> installation will serve: Residence Commercial_ Other J1 <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.L& Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest. Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Sire Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line. <br /> DISPOSAL PONDS El <br /> I 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 /> Homo owner or licensed agents signature certifies 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 /> certifIits the following: "I certify that in the performance of the work for whicFt this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Calif ince." <br /> The6pplicant cal or all r r rnspectio}ns. Complete drawing an reverse side. <br /> Sign�1{�d <br /> Date: <br /> I <br /> E R DEPARTMENT USE ONLY <br /> G <br /> Application Accepted Ib,y rocd ADate �` f <br /> NAA r-1-1 Area <br /> � A <br /> Pit rout I ction by Date Final Inspection by_ � ,1e- _Gl Date r - e6 <br /> Additional Comments: 1 tL - U _. <br /> - � S <br /> Applicant - Return all copies t San Joaquin Co ty Pub is Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> + EH 13-24{AEV.It 5YA �o —`fv <br /> EH;4-2a , V IJ � � V <br />