Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-8420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> EXPIRES 1 YEAR FROM D E V <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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> ! City �� Lot Size/Acreage <br /> Job Address <br /> [' ,�/� * Phone <br /> Owner's Name ����iJ J � Address <br /> icl <br /> Contractor G Address. License No. <br /> Phone <br /> TYPE OF WELL/PUMP:, y - ;NEW WELL ❑,J y `WELL REPLACEMENT ❑ DESTRUCTION D Out of Service Well ❑ <br /> P 6MFl INSTALLATION._L7 =;r.=-.- �- '�"SYS7EM REPAIR <br /> OTHER- ❑ Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK , ' ti 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 /> G1 Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> C-1 Domestic/Private ❑ Gravel Pack L7 Tracy Type of Casing Specifications <br /> i"I Public l_1 Other 171 Delta Depth of Grout Seal Type of Grout <br /> .. 1 <br /> Irrigation 3 —Approx. Depth I Eastern Surface Seal installed by <br /> Repair Work Doris� 7 Type of Pump <br /> H,p,l -yam 1��� _ State Work Done <br /> Well Destruction �❑ Well Diameter <br /> ^Sealing Material & Depth <br /> t <br /> Depth ,•'Filler Material & Depth <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION TI, REPAIRIADDITION i I DESTRUCTION l I [No septic system permitted if public sewer is Gl <br /> r r - available within 200 feet.) <br /> Installation will serve: Residence___2 Commercial—" Other"' - " <br /> Number of living units: Number of bedrooms y' <br /> Water table depth <br /> Character pf4soil to a depth of 3 feet: <br /> SEPTIC TANK \1 ❑ Type/Mtg; Capacity � 'No. Compartments <br /> PKG. TREATM£NT'PLT, ❑ Method of Disposal <br /> Distance to nearel Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines " Total length/size f <br /> FILTER BED Cl Distance to nearest: c Well Foundation Property Line <br /> 1 <br /> I` a <br />+h SEEPAGE PITS 11 Depth Size T Number y r <br /> SUMPS L1 Distance to nearest: Well '" `� Foundatioh "' Property Line <br /> I <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 cou�ty ordinances, state laws, an <br /> rules and regulations of the San Joaquin County <br /> i Home owner or licensed agent's signature certifies the following: "l var'tily that in the performance of the work for which this permit is issued, I shall not <br /> f 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 following: "I certify that in the performance of the work for which this Permitisissued, I shall employ persons subject to workman's compensa" <br /> tion laws of California." <br /> The all mus calf for all required ' pectin . Comp) a drawing on,r v rse side, <br /> Signed Title:i« --r- Date: <br /> ,� E <br /> 11by FOR-DEPARTMENT USE ONLYi- - t/ Area <br /> Application AcceptDateDate Final Inspection byDPit or Grout Inspec _ _ <br /> Additional Comments: <br /> Applicant - Return e.11 copies to: San Joaquin County Public Health <br /> l Services, Environmental Health Permit/Services t ►; Y <br /> 1601 E. Hazelton Ave.. P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE` j PERMIT'NO. <br /> i INFO p t! <br /> I EH 13-241REV.Iix 51 00 <br /> EH 11.26 <br /> d <br />