Laserfiche WebLink
APPLICATION FOR PERMIT <br /> h SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRoNUENT AL`HEALTH DIVISION <br /> 1►/1, 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON CA 95201 <br /> PE IT SPIRES 1 YEAR %K RATE ISSUER <br /> (Complete in Triplicate) <br /> Application is hereby aade,to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is,made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin Cwutty'*ublic Health Services. <br /> IleJob Address '�lS C7 A I Httetw CityS Lot $ire/Acreage <br /> Owner's Name AG wa TkO b 0--d 6 r Address l $'y S�a L t R' Phone <br /> Contractor Vdt I tk Address ' D r led _V 11-A.-IT License NqQg 'Phone <br /> TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT. 0 DESTRUCTION PLOut of Service Well 0 <br /> PUMP INSTALLATIflt <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Ca" <br /> CI Domestic/Private 0 Gravel Pack 0 Tracy, Type of Casing Specificatiom, <br /> I'1 Ptshk [I Other n Delta Depth of Grout Seal Type of Gtrout <br /> I I Irrigation —.Approx. Depth I 1 Eastern Surface Sept'Instilled by <br /> Repair Work Done U Type of Pump H.P. Sinta,Work <br /> Done Well Destruction Well Diameter 7 Sealing Material Depth <br /> Depth �J�' _ Tiller Material i�+rptlt t <br /> TYPE` F SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION t 1* DESTRUCTION I 1 INo septic system perdtkted it pubfiFlowm is <br /> available within 200 feeM <br /> i� <br /> Instoft0an will serve:.. Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of swd to a depth of 3 fast: Wster t"dbptlt. <br /> SEPTIC TANK. O Type/Mfg Capacity No. ConNpitttsr►te r <br /> PI(Cm-18EATMENT PLT.0 Method of bisposal <br /> Distance to nearest: Well Foundation Property Lina <br /> x7 . <br /> LEACHING LINE 0 No. 8 Length of lines Total length/ ` <br /> FILTER BED O Distance to nearest: Well Foundation Property LIMllf ._ <br /> SEEPAGE PITS I I Dept► Sia Number <br /> SUMPS LI Diane to nearest: Well Foundation Propos ty Line <br /> DISPOSAL PONDS D a <br /> 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county-ardinontes, stats# te, and <br /> rules and regulations of the San Joaquin County {' <br /> Home owner or licensed want's signature certifies the fofi w� mg;_"I c,�rtity.that tn,the perforrtt@pq g1 tth_ c}Sl his�l lit is issued,l shah not <br /> arrlploy any person in suds ri i WEicome object to workmsn'i compensation lam of California."Conttsator`s hifing o sub t ontracting signature <br /> cenifiss the following: "I cattify.0*in the performance of the work for,which thiltl,parmit is issued,I shall employ potions subject to workmen's oompenea- <br /> tion laves of California:" <br /> The applicant must call for all rept** CouW4%drawing on reverse side. <br /> 1 <br /> Si Title: �. ���.. Date: <br /> g , . <br /> _..,_, ..._._. .._.. . __..FOA DEPARTMENT USE ONLY <br />' AppkstioAccepted by &S-la-re Date -- <br />~ Pk o Grout inspection by _�' Oats Final inspection by � at+t <br /> _ k <br /> Additional Comments: <br /> Applicant Return all copies to: San Joaquin County Public Health <br /> Services, Ettvironaental Health Perait/Services <br /> 1601 B. Hazelton Ave., P 0 Bax 2009, Stockton, CA '95201 <br /> FEE AMOUNT DUE, AMOUNT REMITTED CASH RECEIVED BY DATE' PERMIT'N0. <br /> INFO <br /> • EH 1324 RIEV.1 i e 51 _�_t JtJ-.. _ ' <br /> EH 14.19 <br />