Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY Pt7BLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E: HAZELTON AVE: ; PHONE (209)46$-3420 <br /> P 0 BOX 2009i: STOCKTON; CA 95201. <br /> -k MIT EXPIRES 1„YEAR FROM PAIR,ISSUED <br /> (Complete in Triplicate) <br /> Application ie hExeby $bide to Sen :Yoagnin County for fi permit to donstiuct and/or inat&li the Vork herein described. This <br /> application ie made in compliance 'with San Joaquin County Ordinancb No. 549 and 1862 Aird the Rules and Regulations of San <br /> Joaquin County Publie Heim sekvicedi <br /> Job Address City Lot SiWAcreage '. <br /> Owner's Name Oao!�,n ye)6Ya mro-li- Address f� f '] Phone 3 <br /> Contraclor �1 Addie-tt '' I ? Licerisls W. - Phone . a <br /> TYPE OF WELL/PUMP:P: VNEWWELL,R WELL REPLACEMENT 0 DESTRUCTION 0 Out of service Well 0 sj <br /> PUMP INSULLATION Sy$tEM AEPAIR b b7H0 D Monitoring 41611 E7 <br /> DISTANCE TO NEARESt: SEPTIC TANk SEWER LINES DISPOSAL FLU. PROP. LINE i,jen <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS z_, y <br /> q, <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTAUCtION SPECIFICATIONS <br /> f7 Industrial Open Bottom 0 Manteca Die: of Well Excavation_ %3 = .� Dia. at Well Casino <br /> !l z,. <br /> Domestic/Private 0 Gravel Pack 0 Tracy TV06 of 610ing v� ,{ ;_;•__ Specifications t <br /> s. <br /> I'I Public t:l Other 11 Delta Depth oi' Grout Seal �f /11/ <br /> p Type of Grout <br /> I I Irrioation qL3- `ApproX. Depth I 1 EAslern Surface Seal Installed by4-4� Y1 �•-,� i. <br /> Repair Work Done [7 Type of Pump _ H.P. . 7� _ . Stat6 W6rk Done_ <br /> Well Destruction CI Well Diametet Seaiirlj; 9iiteriAl R Depth <br /> Depth Filler itettftki i b6pth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 INo Septic system permitted if public sewer is ;;I <br /> available Within 200 feec1 ,i <br /> Installation will serve: ; Residence�:,. Cbmrilercial— v Othet <br /> Number of living unifei Nurriber of bedrooms ~�� ,# <br /> Character of soil to g depth.of 3 feels Water table depth <br /> SEPTIC TANK. 0 Typeiwo Capacity No. Compartments <br /> PKG. TREATMENT PLT.0 i Method of Disposal ..` <br /> Distance to nearest: Well Fbundetion Property Line <br /> LEACHING LINE CI No. & Length of lines Total length/sire i ►” <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Ling <br /> SEEPAGE PITS 11 Depth size r Numbet ?` ' <br /> SUMPS 0 Distance to rieare§t: Well Foundation Property Lind <br /> DISPOSAL PONDS 0 ;; ••� r <br /> I hereby certify that I have prepared this applicitioh and that the work wdl tib done in' Accordarice with Sari Joaquin county ordinances; state laws, and <br /> rules and regulations of the San Joaquin County '{ <br /> Home owner or licensed egant's slgnatute certifies the following: ''I certify that in the performance of.'ihe work for which this permit is issued, t shall not <br /> employ any person in such manner as to b43 dma;subject to workman'A cornperisalion Iswe of C66rn:4"Contractor's hiring or sub-contracting signature <br /> certifies the following: "I Certify,that in the pertormence of the work for which thispemit its iisued, I shad p y pArsana iubject to vliorkrrl8n'e compensa• <br /> Non laws of CAliforrila." .. imto z <br /> The applicant must call for all requited in6kciions. Complete drawing lin rev6ise aide: <br /> Signed X.1! / ..i J r ,t Title: pate: f <br /> rie"�F0 EPAifTMEN1'O�aE ONLY <br /> rr ` <br /> Application Act:eptbd by Utile �� /� Area ' <br /> Pit or Gro,[ Inspection by to Final 16ap'fiction by '•. �,� _ Date 1"' <br /> Additional Commedis: <br /> l <br /> Applicant - Return all copies to: San Jba4uid County Public Health + <br /> Services, Environmental Health Permit/$ervioes <br /> 1601 E. Haseltou Ave., P•0 Box 2069; Stockton; to 95201 <br /> FEE CK N <br /> INFO AMOUNT DUE AMOUNT ftENtITTEt) CASH RECEIVED 8Y DAtE PEFIMIT'NO, <br /> EN 14-28 <br /> • EH 1324 MV.i i R 34 <br />