Laserfiche WebLink
/ APPLICATION FOR PERMIT <br /> r S/7 <br /> 130SAN JOAQUIN COUNTY PUBLIC HEALTH STRVICT$ � <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 98201 <br /> (209) 468-3447 i <br />' ZERMIT EXPIRM 1 YEAR tRQX DATE I&%= � <br /> (Complete in Triplicate) <br /> Application is hereby made to San Josquin County for a permit to construct and/or install the work herein described. This <br /> application is made in cotvliance 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 2a I C zo Kee """ N Lot Size/Acreage f Q <br /> Owner's Name Address.�72 3 C C _ <br /> - O Phone <br /> Contractor Q lh Address l�1� <br /> , v 8 D �- r License Na � phone �� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ Monitoring Well <br /> DISTANCE TO WEAREST: SEPTIC TANK" SEWER LINES y 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 17 Tracy Type of Casing Specifications <br /> ,Plubfic C1 Other ❑ Delta •Depth of'Grout Seal Type of Grout M <br /> 0 Irrigation —Approx, De th 11 Eastern Suriac`a-Seas Installed by <br /> Repair Work Done U Type of Pump _ H.P. _r_ , '- State Work Done <br /> erial & , <br /> Well Destruction 0 Well Diameter Sealing MatDepth <br /> Depth Fi11er Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION CI INo septic system permitted if public sewer is <br /> Installation will serve: Residence— Commercial_,_,,, Other ' available within 200 feet.) <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 Capacjty_ No. Compartments <br /> PKG. TREATMENT PLT,❑ <br /> Method of Disposal <br /> I Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines ` Total length/size r__4 <br /> FILTER BED n Distance to nearest: Well r Foundation Property Line i <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line I <br /> DISPOSAL PONDS ❑ t <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 /> 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 /> ii <br /> certifies the following: "I certify that in the performance of the work for which this permit it issued. I shall employ persona subject to workman's compensa• 1 <br /> tion laws of California." <br /> The applicant ust call for all requi ed inspections. Complete drawing on reverse side. <br /> Sign Till :_facS <br /> Date: i <br /> t _�FOIRrQfEAffTMENT USE ONLY �{ <br /> Application Accepted by Date 1�, l Z-) Area <br /> Pit or Grout Inspection by Date Final Inspection byDate <br /> R <br /> Additional Comments: ` <br /> Applicant.-.Re.turn-allcopies to:.. SAN JOAQUIN COUNTY PUBLIC'HEALTH SERVIC9s" .. _ 4' € <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES fff <br /> 445 N SAN JOAQUIN, P O-BOX 2009, STOCKTON. CA 95201 <br /> FEE OUNT DUE MOUNT REK41TTEp CK RECErVEp 8Y 0. <br /> INFO CASH OATE PERMIT NQ {� �} <br /> EM 1124[REV,iixs� �r <br /> l <br /> 70-D-3/ 1 <br /> � J <br /> /d'� ! T ! <br /> EH;4•Ia ' <br />