Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PAWLI <br /> P O BOX 2009, STOCKTON, CA 95201 REQ . �� <br /> (209) 468-3447 16 1992 YEAR <br /> (Complete in Triplicate) SAN JOAQUiN COUNTY <br /> PO sLfC HERLTH SEV <br /> Application is hereby made�toance uithuin SanCJoaquinor a County Ordinanceermit to nstruct No. 549aando1862 and the�IRuuiee d Regu`,Shtt"irein so t�e!io�fi�S�os <br /> application is made in c y <br /> Joaquin County Public Health Services. <br /> Job Address d r City .Lot Size/Acreage <br /> T • t <br /> Owner's Name Address �� Jes. ��°E -- � Phone <br /> lei <br /> Contract c AddresMV ��a_ �. �`—s3C cense N �r -- F'hone..� � <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C'i Out of Service Well 0 <br /> PUMP INSTALLATION ®� SYSTEM REPAIR ❑ OTHER ❑ Monitoring 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 /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [!'Domestic/Private_ ❑ Gravel Pack ❑ Tracy Type of Casing Specificafions <br /> M Public t l Other ❑ Delta Depth of Grout Sea] Type of Grout <br /> M Irrigation ,_._.Approx. Depth 0 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump .�_ H.P. 3 State Work Done <br /> Well Destruction ❑ Well Diameter f l .h.;Sealing Material i Depth IF <br /> Depth i -�. Ft11e'r Material fA Depth <br /> TYPE OF .SEPTIC WORK: NEW"INSTALLATION 0 REPAIR/ADDITION M 'DESTRUCTION 0 INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve:­Residence—. Commerciat— Other - <br /> Number <br /> ther Number of living units: t—.Number of bedrooms <br /> Character of wil to a depth of 3 feet Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Cl Method of Disposal <br /> s� <br /> ` s Y Distance to nearest: . Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire"' Number <br /> SUMPS LI 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 iii 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 California." i <br /> The applicant mus required i -ons. mplete drawing on to rse side.$ <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted byDate � A ea ' <br /> " I <br /> Pit or Grout Inspection by Date Final Inspection by Data <br /> Additional Comments: <br /> Applicant —Return 111 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 05201 <br /> PEE AMOUNT DVE AMOUNT REMITTED.— I IV ITZ RECEiVED BY DATE PERMIT NO. <br /> INFO <br /> J.� <br /> . EH 13.24 TREY.t/K51 <br /> R;(P •�rr� �` A �^^"J <br /> EH 7126 I' J <br /> a <br />