Laserfiche WebLink
{ - APPLICATION FOR PERMIT <br /> M SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> I 1601 E. HAZELTON AVE. , PHONE (209)468-3420 r <br /> t <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PEMIT EXP RES 1 YEAR FROM DATE ED <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 /> Joaquin County Public Health Services. <br /> j Job Address <br /> 10936 S Harlan Rd Cit,French Camnot Size/Acreage $.11 acres <br /> kkEarl Roberts Address PO Box 241 French Cam Phone 982-052 <br /> Owner's Name <br /> Contractor Clark W 11 Iri Address <br /> License too.371 fiD- —Phone4 - <br /> Service well 0 <br /> TYPE OF WELL/PUMP: NEW WELL S1K WELL REPLACEMENT C1 DESTRUCTION ❑ Out Monitoring Well (IPUMP INSTALLATION � SYSTEM REPAIR 12 OTHER O <br /> DISTANCE TO NEAREST: SEPTIC TANK 30V SEWER LINES DISPOSAL FLD.-2-U.L PROP. LINE 4.52— <br /> FOUNDATION <br /> 5'FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rr <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_��'�,.'- Spea.cifications if Well Casing ��2--- <br /> Type of CasingSpecifications -- <br /> .1 Domestic/Private xCxl Gravel Pack C7 Tracy Tye of Grout 9 Sack — <br /> I'i Public 1-1 Other f-1 Delta Depth of Grout Seal <br /> ` I I Irrigation —.Approx. Depth l I Eastern Surface Sea! Installed by <br /> C ark <br /> Repair Work Done 0 Type of Pump ;11h ^ H.P. R - State Work Donu <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION i I DESTRUCTION I I INo s pttiw shirt system emitted if public sewer is <br /> availaI eet <br /> Installation will serve: Residence 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 iength/size <br /> FILTER BED ❑ , Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 1 I Depth Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line , <br /> DISPOSAL PONDS Cl <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: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any parson in such manner as to become subject to workman'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 /> i The applican s all o r trio omplete drawing on reverse side. <br /> 4 Signal Title:VP Clark Well I Date: <br /> i <br /> FO DEPARTMENT USE ONLY � ,� <br /> Application Accepted by Date Area <br /> Pit or.` rout nepection by � � -� Date— Final Inspection b Date <br /> Additional Comments: r�� <br /> r <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> r <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK X CASH <br /> RECEIVED BY DATE PERM17'NO. <br /> INFO !� Z <br /> EH1 �13-241REV.I/ASS �S�' ' 1-a2a3 <br /> EH 71-28 yJ <br />