Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468—$420 ? <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> JRMWIT EXPIRES 1 YEAR FR-09 DATE ISSUED <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 Sen Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Paµ le-laalth Services. <br /> Job Address City Lot Size/Acreage Q <br /> Owner's Name I Address Phone <br /> Contractor Address 5 3 edn cense No.6861 <br /> TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT ❑ DESTRUCTION t of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER C] Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. UNE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU TION SPECIFICATIONS <br /> C] Industrial ❑ Open Bottom ❑ Manteca Dia. of WeH04 � <br /> Dia. of Well Casing <br /> D Domestic/Private 0 Gravel Pack ❑ Tracy Type of CasSpecifications <br /> i'l Public Ll Other F1 Delta D h of GrType of Grout_ Cut-Urs K <br /> I f Irrigation �.Approx. Depth I I Eastern urface Sed <br /> Repair Work Done L7 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter- ce _ Seali rial & Depth <br /> Depth 1� r Filler ter el & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 R7EP IR/ADDITION I I pESTRUkTION # I (No septic system permitted if public sewer is <br /> \ (A available within 200 feet.) <br /> Installation will serve: Residence_ Commercial 0th r \ 1l" <br /> Number of living units: Number of bedr ms 1L. <br /> Character of soil to a depth of 3 feet: l Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 r Method of Disposal <br /> i <br /> Distance to Weare Foundation Property Line <br /> LEACHING LINE 0 No. Lenof lines Total length/size <br /> FILTER BED EllDistan o arest: Well Foundation Property Line <br /> SEEPAGE PITS I Depth Size Number I <br /> SUMPSLl Distance to nearest: Well Foundation Property Line u <br /> ~DISPOSAL PONDS <br /> ;i <br /> I hereby certify that # have reparad is application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the Sq.n aquin 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 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 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 call for all aired inspections. Complete drawing on averse side, // <br /> Signed X Title: 1LJ Date: 6_ QCT <br /> FOR DEPARTMENT USE ONLY <br /> c� e <br /> Application Accepted by 6&1 Ai Date—__���� L D Area " <br /> Pit or Grout Inspection by Date Final.Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM17'NO. <br /> + <br /> Em 13-24 rREV.+/n sl <br /> EHH 11.2e <br />