Laserfiche WebLink
APPLICATION FOR PERMIT <br /> 5t,Do <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> p=11 EXp RES I YE R TE ISSUED <br /> (Complete is Triplicate) <br /> Application In hereby made to Sen Joaquin County for a permit to construct and/or install the work herein described. This <br /> application in made in compliance with San Joaquin County Ordinance No. 544 and 1662 and the Rules and Regulations of Sen <br /> Joaquin County Public Health Services. j <br /> City� Lot Size/Acreage <br /> Job Address - <br /> ` a <br /> t - Address <br /> Owner's NPhone <br /> tri � t <br /> - - dres - &--y -License N°r� Phon <br /> Contra)FE <br /> '— <br /> fTYPE LL/PUMP. fJEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION 0 Out of Service wellikO <br /> ^. ;.r SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well!; 0 <br /> i. PUMP INSTALLATION <br /> s' �- OISPOSALFLD. PROP. LINE <br /> i DISTANCE TO NEAREST: SEPTIC TANK I -S'EWER LINES" - <br /> ( -,7` ,FOUNDATION 1 A6`RICULTURE WELL OTHER WELL p1T5lSUMPS _ ,.`•. <br /> ?INTENDED USE , r TYPE OF WELL PROBLEM AREA %' CONSTRUCTION SPECIFICATIONS } <br /> 3 fl industrial!.t ❑ openBottom ❑ Manteca Die. of Well Excavation ' Dia.,Of Well Casing <br /> U Domestic/Private 1-40 Gra'414sck ❑ Tracy Type of,Casing Specifications.. <br /> _ f <br /> �l�Publie { lws•At:� �� i-1 Other��- ❑ Delta `_ Depth of Grout Seal � Type of Graut <br /> CJ lrripation - - 'APnrox. Depth—❑1ssIern SurfacotSeal Installed by�� <br /> Repair Wofk done 0 Type of Pump "13..P {` State Work Done , <br /> `WOII Destruction O Well Diameter <br /> Depth i Sealing Material i Depth a -, <br /> f '."% '?Filler Material i Depth <br /> - <br /> - TYPE OF SEPTIC WORK; NEW INSTALLATION O .{REPAIR!-ADDITION DESTRUCTION G INo septic system permitted if public sewer is <br /> �1 € available within 200 feet.) <br /> Al� isYI� <br /> ^Installation will serve: Residence� Commercial_.:_..._ Other <br /> I Number of living units: Number of bedrooms <br /> I Character of soil to a depth of 3 feet: . ; _Water table depth ' i - <br /> f <br /> # � SEPTIC-T-ANK-,'-YJ6r--,❑ No, Compartments.:, Type/ _ f � Capacity A <br /> PKG. TREATMENT PLT.Gla k z .* / Method of Disposal <br /> Distancti-to-nearest: swell- f Foundation Property Line <br /> LEACHING LINE Cl No. &L6rtgtFt of lines � Total length/size <br /> I ;. <br /> FILTER BED *' n Distance to nearest: -''{Well � 2 �,Foundati$n- J ^ Propeny Line <br /> SEEPAGE PITS Depth �' Sire '"� Number <br /> 1 SUMPS Distance to nearests.� y Wei <br /> Foundation Property Line <br /> i DISPOSAL PONDS ❑ ___^"� .,. _ . - -- .— - '. <br /> I hereby cenify th -tI 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 awns{or licensed agent's signature canities the following "hcen#y that in the performance of the work for which this permit is issued;I shall not <br /> employ any persoh-in such mannerras to become subject to wofkman's compensation laws of California." Contractor's hiring of sub contracting signature <br /> f ce.itifies the following, "I certify thst in the performance of the work for which this permiti6 issued; I shall employ persons subject to workman's Compansa• <br /> tion laws of Ca4fornis." .,, y moi; 1 <br /> ` The-applican s c I for ail required ins c0 s, Complet drawing on ra tide. IT <br /> Signed Title: DatB'y` <br /> a, ARTMENT4USE ONLY <br /> Application Accepted by Date 1 Area <br /> i Pit or Grout Inspection by , '` j Date Final inspection by Date <br /> r Additional Comments:11 <br /> App"licant - Rettun all copies to: ,SAN JOAQUIN_COUN'PY-.PUBLIC HEALTH SERVICES . <br /> ' ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> ■ 445'N 3AN .TOAQUIN, !� 0 BOX 2008, STOCKTON, CA 85: t <br /> t a d r i�. GGG,, <br /> S r FEECK AMOLrNT DUE--L:- AMOUNT REMITTED ,- CASH yREC-6 BYE " DATE ' PERMIT'NO.' <br /> t INFO , <br /> ..H 13-. <br /> EH;1.26 ��~ <br />