Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZFLTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON."CA 95201 <br /> 9ERl1TT IIJ RNS 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> s <br /> Application .la hereby made,to San Joaquin County fora permit to construct and/or install the work herein described. This <br /> application is made in compliance 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 C t- Lot Site/Acreage <br /> Q f <br /> I Owner's Name "x TJ&D� Address _/x!2 :70- 4� «� Phone <br /> r Contfaclor ` Address ._ G /Il" fi+---License No �Phone <br /> �4 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT-Cl DESTRUCTION C Out of Service Well U <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C <br /> 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 /> {r <br /> 1_1 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia- of Weil Casing <br /> 1 <br /> [I Domestic/Private L! Gravel Pack C7 Tracy Type of Casing Specifications <br /> { (1 Public F': Other O`Delta Depth of Grout Seal M ;Type of Grout (� <br /> I I Irrigation _Approk.Depth.- I I Eastern Surface Sedl Installed by Y <br /> #, Repik Work Done U Type.'of Pump H.P. State Work Done _ <br /> Well Destruction <br /> 0 Well Diameter sealing Material & Depth <br /> Depth Filler Material i Depth r <br /> I TYPE OF,SEPTIC WORK: NEW INSTALLATION REPAIRlAOOITION i I DESTRUCTION i I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> i �i 1 ••'c `. �. �• tea• r <br /> installation willtservd`: Residence_ Coinrnerclat Other <br /> r Number of Gvirig units: Number of bedrooms :r r <br /> r i _. <br /> Character of sail to a depth of 3 feet: J r��„„��!�,�, Water table depth <br /> f � <br /> SEP7IC:TANK :;;,t 0 T UMfg " ' P �- Capacity No. Compartments <br /> . Method of Disposal <br /> PKC. TREATMENT PLT.fl.- ,, i_c , <br /> y " ' c �u�� Foundation 6 Property Line ^ <br /> 1 Distance to'nearest: Well. <br /> LEACHING LINE No. & Length,oLines - a Total length/size <br /> FILTER.BED a CE Distance to nearest. Well Foundation Property Line <br /> 1 SEEPAGE PITS' t I'I `¢ep[h f 7 Size <br /> SUMPS , t Distance to nearest: Well Foundation_ , ' '�T Property Line <br /> DISPOSAL PONDS f❑ t <br /> I hereby terrify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> s rules and regulations of the San,Joaquin County <br /> Home owner of licsnsad'�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 person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub contracting signature <br /> 1 certifies the following: "'I,certify that in the performance of the work for which this permit is issued,1 Shall employ persons subject in workman's compensa <br /> F tion tavvs;of California." ^' t <br /> The applicant must call for all-ro'gpired inspections. Complete%diawing on reverse side. <br /> s Signed Xi i <br /> loop <br /> ' Title: S `a,i� j Date: <br /> -FOR DEPARTMENT USE ONLY € <br /> i Date I 2.. �� Area <br /> Application Accepted by <br /> rout Inspection by ' <br /> Final Inspe <br /> Pit or-G- <br /> Date ction by Date <br /> r <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services. Environmental Health Permit/Services <br /> 1601 E. Razelton Ave., P 0 Box 2009, Stockton, CA 95201 ' <br /> FEEAMOUNT DUE AMOUNT REMITTED CASN RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> EN t4•7a <br />