Laserfiche WebLink
/4 � 3n <br /> 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, STOCKTON, CA 95201 <br /> PFJtMIT EXPIRES 1 YEAR FROM DAJJE I§iSUED <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 San Joaquin County Ordinance No. 549 and 462 and the Rules and Regulations of San <br /> Joaquin County Public Health Servic s. <br /> r <br /> Job Address � City Lot Site/Acreage <br /> Owner's Name Address v ' Phone <br /> r r � k <br /> Contractor cess /p icense No Phone �J <br /> TYPE OF WELL PUMP: NEW WELL ❑ WELL REP CEMENT ❑ DESTRUCTION 0 Out of Service Well Cl <br /> PUMP INSTALLATION ❑ SY EM REPAIR ❑ OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEW LINE DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRIC LT RE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PRO <br /> BLEMCONSTRUCTION SPECIFICATIONS <br /> Cl Industrial ❑ Open Bottom ❑ Dia. of Well Excavation Pia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Type of Casing Specifications <br /> i'1 Public 1-1 Other Cl Depth of Grout Seal Type of Grout <br /> I I Ifeigation —Approx. Depth I I Surface Seal installed by <br /> Repair Work Done U Type of Pump State Work Done_ <br /> Well Destruction ❑ Welt Diameter Sealing terial & Depth <br /> Depth Filler Xateri & epth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITtON rr DESTRUCT))DN i I INo septic system permitted it public sewer is <br /> n avails within 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: Number.of bedrooms _ <br /> Character of soil to a depth of 3 feet: A Water table depth b <br /> SEPTIC TANK. ❑ Type/Mfg Capacity ��(� t7 Na. Compartments <br /> PKG. TREATMENT PLT. ❑ V Method of Dispopal <br /> Distance to nearest: Well 10 Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED D Distance to nearest; Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS <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 . <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 Ca4fornla." <br /> The applicant 79st call for a uired igspections. Complete drawing on reverse side, _ 4�} <br /> Signed * Title: Date: / 0 <br /> F ENT USE ONLY <br /> Application Accepted by Date Ares <br /> Pit or Grout Inspection by Date Final Inspection by Date `� U <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 2069, Stockton, CA 95201 <br /> INCK <br /> CE OVNT DUE AMOUNT REMITTED CASH RECEIVER BY DATE PERMIT N0, <br /> . E1-26IREV.��K51 0�O-D �� G 17o loo <br /> EMH13-2a <br />