Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES , <br /> ENVIRONMENTAL HEALTH DIVISION / <br /> P 0 BOX 2009, sTOCgTON, CA 95201 <br /> (209) 468-3447 / <br /> YEA R FROM DAZE—MMM <br /> (Complete in Triplicate) <br /> Application is hereby made to Sam Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in cosglliance with San Joaquin County Ordinance No. 549 and 1862 and the Aules and Regulations of San <br /> Joaquin County Public Health Services.CAgAl <br /> Job Address City 5 Got Size/Acreage I <br /> Owner's � '1 't ' Phan <br /> Name Addre <br /> i Phe - <br /> Cortilract "Addres �L - Lice e NOp W I <br /> TYPE_OF WELL/PUMP: NEW WELL Cl WELL REPLACEMENT 0 DESTRUCTION 0 Out of Service Well ❑ t <br /> PUMP INSTALLATION Q SYSTEM REPAIR ❑ <br /> OTHER ❑ Monitoring Well <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 .f� " PROBLEM AREAL CONSTRUC'[IpIV Sf EC1�,G14TIONs� _O Mantecaf��. <br /> n Industrial ❑ Open Bottom ' ' ` Dia. of Well Excavation Dia. of Well Casiir <br /> 5 / <br /> 9 <br /> .Specifications ` t <br /> `U Domestic/Privates Cl Gravel Pack 0 Tracy Type of Casing -- r <br /> ❑ Public 1-1 Other ❑ Delta Depth of Grout Seal ­Et. Type of',Grlou <br /> CJ Irrigation —.Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done U Type-of.P-ump, H.P_... ...-.___. ._Sta(e,Wor.k.Done-_ <br /> Well Destruction Q Well Diameter Sealing Material & Depth <br /> t. <br /> Depth Filler Material L Depth <br /> { <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION DESTRUCTION G fNo'sepHc system permitted if public sewer is �y <br /> # r available within 200 feet.1 <br /> Installation will serve: Residence Commercial____ Other I <br /> ' <br /> i Number of living units; _IIRJ Number of bedrooms ___76 _ <br /> # Character of *0 to a depth of 3 feat: a Water table depth ; <br /> SEPTIC TANK.AS�4JS"T), 'Type/Mfg x F`~ + Capacity " " 'No.-Compartments t; <br /> PKG. TREATMENT PLT. 0 5�0� Method of Disposal <br /> istance to nearest: Well Foundati n Property Line f <br /> i =;ate.-•-; � <br /> LEACHING LINEM6-r-X No. &"Length of,lines Total length/sire i K <br /> } FILTER BED ❑ ;Distance to nearest: .Well Foundation Property Line - <br /> . ate- FS y <br /> 11 Depth ,�-�! r. .Sus i Number <br /> r <br /> + SUMPS ` Distance to nearest: Well Foundation/D l� Property Lina <br /> r / �* <br /> DISPOSAL P64DSk n o <br /> I hereby certify that I have prepared this application and that the work'wM be done in accordance with San Joaquin county trdinances, state laws, and <br /> rules and reguiallonti of the San Joaquin t:N nt -- . - ;�.. _ �! -----» - I <br /> Homeowner or licensed agents si$natureh-; f+es the following;' I certify that'ln'tSi performance 6f the work for which this permit is issued, i chalk not <br />+ employ any person in such manner as to become subject to workman's compensation laws of C&lifornia," Contractor's hiring or sub-contracting signature <br /> 'certifies the following: "I certify that in the performance of the work:fof which this Wmit is issued, i shall snipioy persona subject to workman's compinsa•. <br /> tion laws of California." <br /> -The applicant must cell for all require n etions. COMMdrawing. <br /> + <br /> Signs I Title: <br /> Date:' <br /> r Application Accepted by A A Date Area <br /> ! - �.,� <br /> � PIt or Grout"Inspection by 5' {; '��� 'l7aie "I k� t �Final Inspection by Date <br /> i Additional Comments: + `tip C u G �oA,Lditn <br /> Applicant - Ret_uru all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES C-1 <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN. P O BOX 2009, STOCXTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE A PERM17 N0. <br /> INFO t <br /> •SEN 13.2 1REV.+/>1SI --•- ,--�•_ ••-�` <br /> EM i42e - <br /> Ail -- .a... - - <br /> 5 _ <br />