Laserfiche WebLink
APPLICATION FOR PER3dIT <br /> ' SAN JOAQUIN SOUNTY PUBLIC HEALTH SERVICES <br /> r ENVIRONW39T.4Lj;HEALTH DIVISION <br /> P 0 BOX 2069, `'STOCKTON, CA 95201 <br /> �3 (209) 468--3447 <br /> f <br /> PERMIT EXPIRg5 I -YEAR PROM DATE. LIUM <br /> (Complete is Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application Is made in cee>jrliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. ��1 <br /> Job Address �F_lL�]L •._ J 0—P) 4, City t Size/Acreage <br /> Owner'a Name r ddress ���� - 4 t-GL/fL! / r Phone <br /> L _� � v a <br /> COntrdttor: I Tess--- ,? 'Z!MZ License No:— Z 323- Phone 466 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION FrOut of Service Well Cl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well C7 <br /> DISTANCOTO NEAREST: SEPTIC,-T"ANK - _ SEWER LINES--..._..... K — 'c�DISPOSAL,FLD.___-- PROP.-LINE- <br /> FOUNDATION ! AGRICULTURE WELL`)`,t i OTHER WELL PITS/SUMPS .� <br /> � t <br /> INTENDED USE <br /> 'TYPE OF WELL PROBLEM AREA ,C40NSTAUCTlflN SPECIFICATIONS <br /> Ll Industrial O Open Bottom #❑ Manteca dia_`pfsWiI Excavatiori`-° ' !�' _— f Dia` t Well Casing <br /> U DomesticIPrivate ❑ Grav Pack;; L7 Tracy Type of Specifications <br /> ❑ Public fel Other 1I] Delta Depth of-Grout!Seal i Type of"Gro,)t- : <br /> Ci Irrigation .Approx. Depth ;❑ Eastern Surface Seal Installed by sem" <br /> Repair Woo Done Ups of Pump i H.P. �`�---� State Wk Donee 01 ° { OR <br /> Well Destruction 0 Well Diameter / e� Sealing Material i Depth s <br /> Depth_ /IC/��'f— Filler Material & Depth (:f7 <br /> TYPE OF-SEPTIC WORK: NEW INSTALLATIOgLD REPAIR/ADDITION CI DESTRUCTION M INo septic system,permitted if public-sewer is' <br /> � available within 200 feet.) <br /> Installation will serve. Residence— Commercial Other <br /> Number of living units: Number of bedrooms <br /> character,of soil to a depth of 3 feet: Water table depth <br /> SEPTIC LANK ❑ TV"/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT,C1 Method of Disposal <br /> Distance to nearest: ellFoundation Property Line <br /> ZIZ <br /> LEACHING LINE ❑ No. & Length of lines Total length/sire <br /> FIL7Efi�BEf) n Distance to nearest: ell Foundation Property Line <br /> SEEPACrtE1PITS l I Depth Sire Number ' <br /> SUMPS-1 I LI Distance to near st: Weil Faun ion Pro s <br /> perry Lina <br /> DISPOSAL OONDS ❑ <br /> I hereby cenify 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 licen d agent's signature certifies the following: "I cenify that in the performance of the work for which this permit is issued, I shall not; f <br /> employ any per In sus nner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> cernfist the t owing: "!C ify that in the performan of the work for which this permit is issued;-1 shall employ persons subject to workman's compensa•l <br /> tion laws o Calif la." <br /> 1 <br /> The apps' ant m r all re uir n Comp! Ing on r side. <br /> } <br /> Signed Title: Date: -/46 <br /> OR EPARTMENT USE ONLY <br /> Application Accepted by Date .!�12S- Area <br /> Pit or Grout Inspection by Date Final Inspection by kasy� Date <br /> Additional Comments: F <br /> Applicant Return oLU copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES `t / <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 'S:07!=� f / [ <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 f i <br /> ` FEE <br /> INFOFAMOUNT 611E AMOUNT REMITTEO CASH RECEIVED By DATE PERMt7'N0. ' 3— 36 <br /> — - t <br /> T EH 114-M 3 <br /> t►I"trN'111EV"iins <br /> i <br />