Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> �n ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSURD <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 Stade 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 /> r <br /> .p 6 <br /> Job Address � S /City VY,/fCQ Lot Size/Acreage <br /> Owner's Name �tfY1'y Aef77�er-�. Address 3 �� �p,s�� -- - --- Phone �Z <br /> Contractor �� 6�rAddress r �.>" e License No. 9 -$'73Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION ❑ Out of Service Well L"1 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHEe ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: _SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL FITS/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 /> C-I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> ('I Public EI Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing Material i Depth <br /> Depth !'filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 1 DESTRUCTIONK INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> `"-,�—Installation will serve: Residence— Commercial— Other 1 <br /> Number of living units: Number of bedrooms ` <br /> Character of soil to a depth of 3 fast: -S'.4 AN - Water table depth <br /> SEPTIC TANK W Type/Mfg Caar�!LU Capacity /",o No. Compartments <br /> PKG. TREATMENT PLT.0 �00 Method of <br /> Disposal <br /> Distance to nearest: Well NIA Foundation .- 1 _ Property Line . <br /> � I <br /> LEACHING LINE Cl No. 8 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest. Well Foundation Property Line - J' <br /> SEEPAGE PITS 11 Depth Size Number <br /> i <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 in accordance with San Joaquin county ordinances, state laws, and i <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's mignsiure 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 workmen'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." <br /> The applicant must call for alt required inspections. Complete drawing on reverse side. <br /> Signed Title: Z ^E +?/z _ Date: y^/_9 3 <br /> DEPARTMENT USE ONLY <br /> R <br /> 1 <br /> Application Accepted by Date Are <br /> Ph or Grout InspocWn by Date Final Inspection by Dats��P <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 2005, Stkn, CA 95201FEE <br /> 1 <br /> INFO AUNT DUE AMOUNT REMITTED K H REC ED Y DATE PERMIT'NO. ' <br /> Mx <br /> + EM 1571 TREY.t�ltsl <br /> EH 14.20 <br />