Laserfiche WebLink
r .T <br /> APPLICATION FOR PERF I T` <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENNTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE ,,(209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> �( <br /> PERMIT EXPIRES 1 YEAR FROM DATE SU <br /> (Complete -in Triplicate) <br /> Application is hereby made 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 1$62 and the Rules and Regulations of San <br /> L Joaquin County Public Health Services. <br /> Job Address A 7 O 517 fi u-Ed City Lot Sire/Acreage <br /> Owner's Name Address 70 5-7 �f r d_ _Ad, PhoneJFS l <br /> i tj <br /> ContractorJZJ <br /> _LIZ Address 1C ! License No. aLL2sCJPhone <br /> TYPE OF WELL/PUMP:. NEW WELL WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C7 OTHER ❑ Monitoring Well f7 <br /> FDISTANCE TO NEAREST: SEPTIC TANK Py-P - SEWER LINES ' DISPOSAL FLD. PROP. LINE <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS// �. <br /> 1 C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casi�t f <br /> 11 Domestic/Private ^Gravel Pack �&acy Type of Casing_�]�f 61T Specifications <br /> l'1 ublic 1-1 Other n Delta Depth of Grout Seal Type of Grout MC/' <br /> 1W,Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done — (j <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Materiel i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> -� - available within 200 last.) <br /> Installation will serve; Residence Commer�° <br /> Number of living units: Number of bedroQ� Ani i I � ,E} <br /> .Character of soil to a depth of 3 feet: y E*_'A 4 flwfl wwWater table depth <br /> SEPTIC TANK. ❑ Type/Mfg perFAft rnay varil4fa�t j No. Compartments <br /> PKC. TREATMENT PLT. C7 1� dMethod of Disposal <br /> U <br /> Distance to nearest: \W i�1.. � i� ��i. opperty Line <br /> vision <br /> LEACHING LINE ❑ No. fir Length of lines Total length/size N <br /> FILTER BED O Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS U <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 /> 6 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 shell 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: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tlon laws of California." <br /> The applicant st c I for f �Inspacl�C�-pledrawing on re r side. <br /> r <br /> i Signed Title: Data: <br /> 11 <br /> FOR DEPARTMENT USE ONLY <br />' Application Accepted by Date Area 46 ,6 <br /> Pit or Grout Inspection by Data Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED PATE <br /> PERM17 NO. <br /> INF <br /> ,.l:N1lI1fREV.1/rtil � i r �(� Ah- O <br /> EH t1.2e / ITS <br />