Laserfiche WebLink
1 <br /> F <br /> APPLICATION FOR PERMIT S <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION N-0 W <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 1 <br /> P O BOX 2009, STOCgTON, CA 95201 CK <br /> PERMIT EXPIRES I YEAR FROM DATE 19SPEU 10151 �� r <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 /> Job Address <br /> S' City �If Lot Size/Acreage <br /> Owner's Name e, k L I e LC E L Address 's Phone okeL <br /> _ J <br /> Contractor -F�S'l� 2099.2—Address EL- License No. ��-��-7� _Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Ll Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ _SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK - `SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/P'rivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1'1 Public (1 Other 171 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by t� <br /> Repair Work Done U Type of Pump H.P. State Work Done_ <br /> Wait Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INS:7, <br /> ION 1A REPAIR/ADDITION I I DESTRUCTION INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> +Il 1 <br /> Number of iiving units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Comp±rtmsnis <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE El No. b Length of lines Total lengthtsize r <br /> FILTER 8£D ❑ Distance to nearest: Well Foundation Property Line Z <br /> SEEPAGE PITS 11 Depth Size Number _ <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line Ar <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 /> rubs and regulations of the San Joaquin County -=- <br /> Home owner or licensed agent's iignsture candies 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 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 call for all required inspections. Complete drawing on reverse side. <br /> Signed X_ �✓ « Title: Date: /Q `2-1-9 Z <br /> OR-DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date l? a' �, Area O Z 1 <br /> Pit or Grout Inspection by Date Final Inspection by Date `7 <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 Vol <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'Nd. <br /> INFO "�CQAySIH '1!� 4 q 7 <br /> . EH t744111EV.r/crit Sly ' <br /> 14 . , tie V iL ✓��~tY'd``,�' 1p�` 35 'V <br /> EH 14.7e <br />