Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> i (209) "468-3447 <br /> c <br /> R --Lro e_zl6ftATE <br /> (Complete in Triplicate) �� �pjA <br /> �� he�ei d e This <br /> Application is hereby made to San Joaquin County for a permit to construct and/or ins ti of Ban <br /> application is made in eer�rliance vith San Joaquin County Or <br /> No. 544 and 18b2 and �'� �d <br /> Joaquin County Public Health Services. <br /> fS <br /> City Lot'Size/Acr%� <br /> Job Address "Address <br /> � �'�p S' <br /> VW'Ad e �� L , Sl L�LJ4-•1u� Phone �j <br /> Owner's Name <br /> • Contractor <br /> Dgkoj`Asress Zq S b. � —License No. s Phone <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT C] DESTRUCTION 0 Out of Service well Cl <br /> SOIL ��r�R �-sl 2.Monitoring <br /> PUMP INSTALLATION El SYSTEM J SYSTEM REPAIR <br /> FLD. PROP. LINE <br /> DISTANCE TO NEAREST;:SEPTIC TANK SEWER LINES — DISPOSAL 4 <br /> t FOUNDATION .,��.� AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFI TIONS �� A <br /> C1 Inductriel ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casin <br /> Domestic/private ❑ Gravel PacV� L7 Tracy Type of Casing PSIC, - Specifications <br /> IM Public Other n p Delta Depth of Grant Seal Z Type of Grout <br /> GI Irriganen �..a 64 Eastern Surface Seal Installed by s�"G <br /> Repair Work Done 0 Type of Pump H.P. State Work Dona <br /> Well Destruction O Well Diameter <br /> Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION 0 (No septic system <br /> m perm <br /> avafe��tked i ! public sewer is <br /> Installation will serve: Residence— Commercial— Other <br /> i 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 Capacity No. Compartments <br /> PKG. TREATMENT PLT, 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> r " <br /> LEACHING LINE C'1 No. & Length of lines Total length/size- <br /> FILTER BED CI Distance to nearest: Well Foundation Property Line <br /> II SEEPAGE PITS I I - Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Lina <br /> DISPOSAL. PONDS 0 <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 /> certifies the following: "1 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 /> v The applicant m at call for a re iced ins ctions. Complete drawing on reverse side.` y <br /> Signed X_�.� - Titles �� �^ �C�{ l - Date: f <br /> RTMENT USE ONLY <br /> Application Accepted by Date S <br /> r <br /> Pit or Grout Inspection b Date Final Inspection by Date <br /> Additional Comments, Of <br /> Applicant Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2000, STUCKTON, CA 95201 <br /> FEE AMOUNT OUE AMOUNT REMITTED CASH RECEIVED BY GATE PERMIT0. <br /> INFO LWJ�j // 9� Y 5/ 17/ t /47� <br /> EN 14.26 <br />