Laserfiche WebLink
APPLICATION FOR PERMIT l <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � if <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468--3420 <br /> P O BOX 2009, STOCKTON, CA 95201 ED <br /> 13 EXRES 1 YEAR FROM DA <br /> P 1 � <br /> (Complete in Triplicate) �r <br /> ce No. 549 and 1862 and the Rul s an$d egulations of San <br /> Application is hereby made to San'Joaquin County for a permit to construct and/or install the Wor herein described. This <br /> application is made in complianeeiWith n Joaquin County OrdinLx� I A 1 <br /> Joaquin County Publ Health Services. 3 r L <br /> 1 S' Lot Size/Acreage <br /> City <br /> Job Address <br /> Phone <br /> Address <br /> Owner's Name <br /> actor Address <br /> License No. _�------Phone <br /> NEW WELL 0 WELL REPLACEMENT 1-1DESTRUCTION ❑ Out of Service Well ❑ <br /> TYPE OF WELL/PUMP: OTHER ❑ Monitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR © I <br /> SEWER LINES DISPOSAL fLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS <br /> FOUNDATION � AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> f 1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications — <br /> ❑ Tracy Type of Casing <br /> f 1 Domestic/Private ❑ Gravel Pa Depth of Grout Seal Type of Grout <br /> I:1 Other F1 Delta <br /> I'1 Public Surface Seal installed by <br /> 4 I I Irrigation —..Approx.�Depth 11 Eastern <br /> k4H P <br /> _�---- State Work bona <br /> Repair Work Done Type of Pump <br /> (3 <br /> Sealing Material & Depth <br /> Well Destruction ❑ Well Diamet --- -- Filler Material 5 Depth <br /> Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION aNailablerwnhin 200 leelc sYste .t ed if public sewer Is ' <br /> t' Installation will serve; Residence i Commercial Other -- <br /> r Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet. No. Compartments <br /> Ik SEPTiC TANK 0 Type/Mfg Capacity--- <br /> Method of Disposal <br /> PKG. TREATMENT PLT. 0Property Line -- <br /> Distance to nearest: Well Foundation i <br /> �l Total length/size <br /> LEACHING LINE ❑ No. & Leingth of lines Property Line <br /> FILTER <br /> TBED ❑ Distanc' to nearest: Wel! Foundation p Y <br /> :f <br /> Size _ Number <br /> SEEPAGE PITS k I Depth Property tine <br /> SUMPS 0 Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ <br /> I hereby cenily that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an <br /> rules and regulations of the San Joaquin County <br /> ollowing: "I certify that in the performance of the work for which this permit is issued, I sh <br /> Home owner or licensed agent's signature certifies the fall not <br /> I employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the fo wing: u certify that tri he performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> f tion laws o Cali mia." <br /> 1 The appli ant st call for all required in ions. Complete drawing on reverse side. �r O <br /> N/' Title: Date: <br /> kJ�Signed X <br /> Y E ONLY <br /> Date #3— L— .Are a <br /> Applica on Accepted by <br /> ! Final Inspection by Date <br /> Pit or Grout Inspection by Date --- <br /> Additional Comments: <br /> Applicant — Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2449, Stockton, CA 95201 <br /> CK RECEIVED BY DATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO 9re 4,2 <br /> . EH 13.24 IREV. n 51 35 Q� ✓ i <br /> k EH S4 2e JJ <br />