Laserfiche WebLink
APPLICATION FOR PERMIT y <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONNdENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON* CA 95201 <br /> PERMIT E%PIRES I YW FROM DATE ISSUED <br /> (Complete. in Triplicate) <br /> Applis hmadebirs caepliansce irithuSan i countyin Counr a ty ordinanceconstruct <br /> No. 549and/or <br /> le62 and thethe <br /> Rules andherein <br /> Regulationsdof SanThis <br /> application <br /> Joaquin County Public Health Services. 60 f A,6 U � <br /> J C 1z0/h,,f;l� CityLot Size/Acreage <br /> Job Address. �}^f <br /> ��tr` 't E4 Address Phone <br /> Owner's Name r <br /> � P f� .?� �� >_ t`�icense No. Phone � <br /> Contractors Ll.� Address Se <br /> rvlce Well, <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION ❑ put 14onitoring`We]l ❑ <br /> ...PUMP INSTALLATION C] SYSTEM REPAIR`❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - <br /> DISPOSAL'FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL -PITS/SUMPS <br /> +k F <br /> _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS —1Digof Well Casing <br /> C1-lnduatriat { ❑ Dpen Bottom ❑ Manteca Dia. of Well Excavation <br /> Specifications <br /> t I Domestic/Private ❑ Gravel Pack t ❑ Tracy Type of Casing Type of Grout_ <br /> ["1 Public lel Other n Delta Depth o1 Grout SealO <br /> I I Irrigation —.Approx. Depth I l Eastern Surface Soul Installed by C!7 <br /> H.P. State Work Done <br /> Repair Work Done L7 Type of Pump Sealing Material' i Depth " <br /> Well Destruction ❑ Well Diameter A , :. t <br /> Depth Filler Material i Depth [ , <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I I al o sep4tiwshin m feat,ed:it public sewer is <br /> Installation will serve: Residence Commerciely Other r <br /> Number of living units: Number of bedrooms de <br /> th ; <br /> Character of tog to a depth of 3 fest: Water tab p <br /> O L,e,^, `-L� Capacity No. Compartments <br /> I SEPTIC TANK. ❑ Type/Mfg ., <br /> PKG. TREATMENT PLT. ❑ r r / r Method of eDit.1 , Q <br />+ r Property Line <br /> I Distance to nearest: Well ! Foundation Y t <br /> LEACHING LINE No. 6 Length of Total leng[h`/size <br /> tinea, - r j <br />+F FILTER BED ❑ Distance to nearest: well Foundation �— .Property Line <br /> 1f` SEEPAGE PITS �'I` Depth _ Size Number <br /> SUMPS Lf Distance to nearest: Well Foundation /d'f _ Property Line <br /> a <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in acd-ance�wilh San Joaquin county ordinances, state laws, an <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, l shall not <br /> mpensation laws of California... Contractor's hiring or sut>contracting signature <br /> employ any person in such manner as to become subject to workman's co <br /> f 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 componsa- <br /> + tion laws of California." <br /> kThe applicant must wll1 required in ions. Complete drawing on reverse sid t / Q <br /> iTitle: '� Dated <br /> Signed r <br /> FOR DEPARTMENT USE ONLY 1 <br /> ' Z <br /> � } Date'. `� <br /> Application Accepted by Area <br /> Pit or Grout Inspection by :- Oto� - Final Inspeetion by 'Date <br /> _ � .L _ _. <br /> Additional Comments: <br /> i 4 r <br /> " Applicant - Return all copies to: San oaqulo County-Publi, ealth Services <br /> ,Environmental Health permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn;'CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'N0. <br /> INFO <br /> � Il ! �jC�ASH <br /> . EXt}21t11EY.��xsr �J1. OCA r35 2 <br /> EX i�•76 - - - - ,, r � y <br />