Laserfiche WebLink
E APPLICATION FOR PERMIT <br /> f � <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> 9 <br /> RES 1 YEAR FROM DAT <br /> (Complete in Triplicate) <br /> Application is hereby made to SanJoaquinCounty for a permit to construct and/or install the work herein described. This <br /> application is made in conpliance'vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address City �-010/ Lot Size/Acreage 7`Qf�Cr <br /> i <br /> Owner's Name 1 Address Phone <br /> 1 j _ �r <br /> Contractor 1 --�, •_,( Address -2�) j U dF/ a License No. _,?C)S-7�� Phone 36d,3��� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ <br /> 1 PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> 4 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE A TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L} industrial ❑ Open Bottom' D Manteca Dia. of Well Excavation Dia. of Well Casing <br /> r) Domestic/Private ❑ Gravel Pack e . Ll Tracy Type of Casing , <br /> ' Specifications <br /> 1"1 Public 1:1 Other n Delta Depth of Grout Seal <br /> Type of Grout T\ <br /> l I Irrigation Approx._Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done LJ Type of Pump H.A. State Work Done 4 <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth ,Filler Material & Depth . , r--- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION �n <br /> O r I�YDESTRUCTION [ I ifYo septic system permitted if public sewer is U <br /> I <br /> to- available within 200'feet.) <br /> Installation will server Reside ce Commercial— Other ` <br /> Number of living units: �� Number of bedroo"s <br /> Character of soil to a{depth of"3 feet: -5'si49Lon-+- Water table depth <br /> SEPTIC TANK. C?'-'Type/Mfg C� 1� '. <br /> Capacity Q� No. Compartments <br /> PKG. TREATMENT PLT. ❑ - r <br /> Method of Disposal <br /> Distance to,`nearest: Well-` Foundation: /O / <br /> Property Line -r <br /> t LEACHING LINE 2T-No. & Length of lines / Total length/size ,_ w <br /> FILTER BED 1-4-Distance to nearest: Well 2-201y- Foundation � <br /> a Property Line <br /> SEEPAGE PITS Iti- Depth . T-t -Bile '2r Number <br /> SUMPS LI Distance to'nearest" Well 11004Foundation /O <br /> ProyD <br /> perty Lina <br /> DISPOSAL PONDS k ❑ <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 certifies the following: 111 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 /> certifies the following: "I certify that in the �ormancs of the work for;which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." j <br /> The applica t must call for all require ins ctions. Complete drawing on reverse side:- --- --- 1 <br /> Signed Title: &J AJI �C7 <br /> Date: <br /> f <br /> FOR EPARTMENT USE ONLY <br /> Application Accepted by ([+rv� Date 0AC_ <br /> �or <br /> rea Grout Inspection by Date. Final Inspection by ate _ <br /> Additional Comments: <br /> Applicant - Return all copies to: SSan Joaquin County Public Rea lth. ,:; .,N <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> ffF09UNTDUE 1 <br /> 1 AMOUNT REMITTEDffi <br /> RECEIVE[] BY DATE PERMIT'NO. <br /> Eli 13-24 IREV.1 51 7U r�EH 41.26 <br />