Laserfiche WebLink
i <br /> APPLICATION FOR PERMIT <br /> jy~fig SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> U0 ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN-JOAQUIN, PHONE (209)468-3420 <br /> P <br /> 0 13O% 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES l Y FR M D TE ISSUED <br /> i (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This -1 <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San' <br /> r Joaquin County Public Health Services. k ' <br /> 111110,17 9_�12, City Lot Size/Acreage # <br /> I Job Address - Phone ti_*21 <br /> Address SA� <br /> Owner's Name Y7 L r r <br /> k& 3 <br /> - � G Ss Address j�� License NoV73 —Phone <br /> Contractor DESTRUCTION ❑ Out of Service well ❑ <br /> TYPE OF WELOPUMP: NEW WELL ,x. WELL REPLACEMENT n 14onitoring Well n <br /> PUMP INSTALLATION .04 :. SYSTEM REPAIR 0 _ OTHER © ` <br /> r+ OSAL FLD.LL PROP. LINE �v <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPP1Yg/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL— <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE c S <br /> f - Clpen Bottom ❑.,Manteca \ Dia, of Well Excavation':N::: _ 'Dia. of Well Casing !+1 <br /> n Industrial !- Specifications T�llFa <br /> .Type of Casing_ — v <br /> Domestic/Private Gravel Pack vn-T•racy Type of Grout <br /> I'1 Public I-) Other ['1 Pelta r Depth sol Grout Seal �Q , <br /> I i Irrigation Z g'�.Appro 0813th It I Eastern Surface Seal Installed by ~� di <br /> of Pump S�� t H•P•' �• State Work Done <br /> Repair Work Done U Type I _ Sealing Material i Depth <br /> Well Destruction ❑ Well Diameter Muer Material iDepth-. <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I availabielwkhin 204 feet`ied'I public sec system wer is ' <br /> "' Installation will^seme: Residence Commercial Other <br /> Number of-living units: _Number of,bedrooms r <br /> F Character of wN to a depth of 3 feet:' Water table depth <br /> ' 4No. Compartments; <br /> SEPTIC TANK r❑ Type/Mfg Capacity— <br /> - <br /> -. PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> i LEACHING LINE ❑ No. 6-Length of lines• Total lengthlsize <br /> Y FILTER BED ❑ Distanca•to dearest: l Well Foundation Property Line <br /> r <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation .Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that 1 have prepared this application and that the work will be done in accoidarice with San Joaquin county ordinances. state laws, and <br /> rules and regulations of the San Joaquin County <br /> r 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-shslLnoot. <br /> o employ any parson in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub contracting signature <br /> certifies the following: "I certify that in the psrfofmance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> ( The applicant must for all req fired inspections. Complete drawing on reverse side. <br /> { Signed Title dCn.ih - Date:—- <br /> F R DEPARTMENT USE ONLY pf� <br /> r \.. <br /> Date Area <br /> V Z 1 <br /> Applicatio Accepted by <br /> J �{ -�3 <br /> Pit or Inspection by Date ( Final Inspection by Data <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 O Box 2009, Stkn, CA 95201 <br /> FEE CK RECEIVED SY DATE PERMIT'NO, <br /> INF AMOUNT DUE AMOUNT REMITTED CASH <br /> . EH U-24 111EV.1 i lr 51 fj t7 <br /> o X757 f13 I1-��5� qct-3 9 <br /> 0414-211 �— <br />