Laserfiche WebLink
APPLICATION FOR PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />1601 E. HAZELTON AVE., PHONE (209)468-3420 <br />P 0 BOX 2009, ST'OCKTON, CA 95201 <br />J?8_I E PYRES 1 YEAR FROM RATE ISSUED <br />(Completer 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 />%C.9. rp, ' 'Yl .f}�l//.!/ W r:.. (/t 5J51 ?42-[7 Lot Size/Acreage <br />Owner's Name ���W Address L! 9.�0{fw yY Phone <br />Conlraclor �dxiZ Via Address.' i- r -1 6-% License NO3_2-? _� Phone <br />TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT O DESTRUCTION O Out of Service Well Gl <br />_ PUMP INSTALLATION O SYSTEM REPAIR O OTHER 0 Nonitoring Well q <br />DISTANCE TO NEAREST: SEPTIC TANK' SEWER_LINES.__.... 'DISPOSAL FLO. PROP. LINE <br />i FOUNDATION AGRICULTURE WELL OTfIER WELL PITS/SUMPS <br />INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />n 1,ndustriai O Open Bottom O Manteca Dia. of Welt Excavation Dia. of Wall Casing <br />fa Domestic/Private O Gravel- Pack O Trac Type of Casing- Specifications <br />I'I f'tiblic I:1 Other fl Delt� Depth of Grout Seat 1 ,__ Type of Grout <br />I I Irripaoon Approx. Depth I I Eastern Surface Seal Installed by <br />Repair Work Done U Type of Pump H. P. _ State Work Done <br />Well Destruction O Well Diameter Sealing Material & Depth <br />I' Depth Filler Material & bepth <br />TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION 1 1 (No septic system permitted -if public suwer is <br />pA availablo'Wilhin 200�`f/feet.► <br />Installation will serve: 'Residence — Commercial _ Other d{id yC , tdr h� a woes <br />Number of living units: .Number of bedr dl- <br />Character of soil to a dopth'of.3 feet: Water table depth&/ <br />SEPTIC TANK O Type/Mfg Capacity No, Compartments <br />PKG. TREATMENT PLT, O Method of Disposal <br />Distance to nearest.-_ Well Foundation _ Property Lino <br />LEACHIh LINE 0 No. & Length of lines Q �_ Total length/size <br />FILTER BED n Distance to nearest; Well Foundation Property Line <br />SEEPAGE PITS 11 Depth _ Sire Number <br />SUMPS LI Distance to. nearest: . Well Foundation Property,& ins <br />DISPOSAL PONDS O ' <br />V'\ <br />D <br />I hereby certify that I have prepared this application and that the work will be dono in accordance with San Joaquin county ordinances, state laws, and <br />rules and regulations of tho San Joaquin County <br />Homo 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 poison 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 porsons subject to workman's compensa• <br />tion laws of California." <br />The applicant must I for all eq 'red' pectlons. Complete drawing on reverse si <br />Signed X isle; �—/ Data; <br />OR DEPARTMENT USE ONLY <br />Application Accepted b �p�_w Area <br />Pit or Grout Inspection by _ Data Final Inspection t1}L`��IY\ ) -= <br />Additional Comments <br />Applicant - Return all copies to: San Joaquin County Public Health <br />Services, Environmental Health Permit/Services <br />1601 E. Razeltou Ave., P 0 Box 2009, Stockton, CA 95201 <br />EH 13.241 REV. 1, M S1 <br />EH 1e-211 <br />FEE <br />F O' <br />AMOUNT DUE <br />AMOUNT REMITTED <br />CASH <br />RECEIVED eY <br />DATE <br />PERMIT' NO. <br />