Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � <br /> ,] ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> 'EAR <br /> (Complete in Triplicate) <br /> Application is hereby made td San Joaquin County for a permit to construct and/or install the work herein described. This <br /> om <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules amd Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 38 <br /> tp( (L City_ftLot Site/Acreage <br /> SO- 7153 r <br /> Owner's Name ���`^`^ �(.�--_ Address �h'`'em Phone <br /> ��1f� QSS S Address • Llnc,�la License No.630672- Phone �q ` <br /> Cantraclor!`sem.._ — Q__ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F-Y DESTRUCTION t of Service Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 Monitoring 01 Well C7 <br /> DISTANCE TO NEAREST; SEPTIC TANK 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 /> F1 Industrial pen Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing <br /> CJ Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing, __ Zd Specifications <br /> A Public 1.1 Other ' ❑ Delta Depth of Grout Seal O a Type of Grout <br /> GI IrnOation Approx. Depth 0 Eastern Surface Seal Installed by <br /> Repair Work Done Dyy of Pump H.P. St to Work Done <br /> Welt Destruction Well Diameter Sealing Materiel i Depth <br /> Depth Filler Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION n REPAIR/ADDITION Z1 DESTRUCTION 0 INo septic system permitted if public sewer is <br /> 1 available within 200 feet.) <br /> Installation will serve: Residence— Commercial— Other i <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 _i Method of Disposal <br /> I Distance to nearest: Well Foundation Property Line ` <br /> LEACHING LINE ❑ No,"& Length of lines `Total length/size (�a <br /> FILTER BED ❑ Dist'Inco to nearest: Well Foundation Property Line ` <br /> y t <br /> SEEPAGE PITS 11 Depth Sire Number <br /> I <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 t <br /> I hereby cenify 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 l r <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," Cont(actor's hiring or subcontracting 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 pall fo re uired inspections:.CpTplete drawing on reverse side. <br /> p r <br /> Signed Title: #° OU)n Q a Date: <br /> R DEPARTMENT USE ONLY <br /> 09!li Application Accepted b09! L Es,� -- -- Date Area z) 14 <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant — Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 88201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY ATE PERMIT'NO. <br /> INFO <br /> . EH 13.74 IREV,I/K 54 <br />