Laserfiche WebLink
APPLICATION FOR PERMIT <br /> A7 SAN JOA UIN COUNTY TX PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468--3420 <br /> ' P 0 BOX 2009, STOCKTON, CA 95201 <br /> P IT I <br /> MUMS 1 YEAR FROM DATE JQSUED <br /> (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 <br /> M application is made in oemplia.nce with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joequin County Public Health Services <br /> r <br /> Job Address City Lot Size/Acreage <br /> n 1 w <br /> Owner's Name ��Y�/ T A dress. ZJ` i T Phone <br /> �� +� � <br /> `Co-rittyctpr -Address / - - - icense-No-1-5-3.9- -Phone- - <br /> wTYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service W <br /> ell ❑ <br /> 1 PUMP INSTALLATION ❑ YSTEM R IR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK- SEWER LINES DISPOSAL FLD. PROP, LINE { <br /> -'.t-..FOU NDATIONi AGRICULTURE L OTHER,WELL PITS/SUMPS <br /> ► INTENDED USE G *,•_TYPE OF_WELL_ PROBLEM AREA .CO TRUCTION SPECIFICATIONS `_ t �f <br /> C-} Industrial' d ❑ Open Bottom ❑ Manteca a. f Wel!'Excavation Dia:of Well Casing s j <br /> f.a Domestic/Private I D Gravel Pack 0 Tracy _Typo f Casing Specifications 1 <br /> tf'1 Public ` (, Other , ► .,rA ,� F1 Delta �° Dept of Grout Seal Type of Grout W <br /> ,I i Irrigation' —.Approx. Depth " I I Eastern � Surfa a Seal Installed by i �- <br /> "Repair Work Done U Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Will Diame`ter" Sealing Material & Depth <br /> i Depth Filler Material & Depth �} <br /> TYPE OF SEPTIC WORK: MEW INSTALLATION ( REPAIR/ADDITION Il DESTRUCTION I I (No septic s ste <br /> Y i p y permitted if public sewer is <br /> f avlab.lo iinstallation wilt serve: Residence CommercialOther <br /> 1 4" � - + <br /> �,­fJumber'of living units: .Number of.bedrooms <br /> f Character of snit to a depth of 3 feet: A 6'o <br /> E Water table depth <br /> SEPTIC TANK ` ❑ Type/Mfg Capacity Q • ,Na'Compartments <br /> 'PKG. TREATMENT PLT. ❑ nMethod of Di <br /> spo al <br /> ! Distance to nearest: Well_Sfic) _ Foundation Property Line_ <br /> AFLEACHING LINE Cl No. & Lengthoflines To I tangth/size <br /> -FILTER BED - <br /> [! Distance to nearest: Well oundatian property Line <br /> SEEPAGE PITS!L' +-111 JDAA1h .r Size '.'.Nu of <br /> SUMPS C:—Distance-to-nearest: Well ` Foundation <br /> � -.� Property Line � <br /> DISPOSAL PONDS ❑ 1� 4, F f C" , q ` I <br /> 1 hereby certify that F"ffrive prepared this application acid '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 licensed-ag6nt's signature certifies the following: '9 certif that in the } <br /> ,employ an y perfarmance of the work for which this permit is issued, I shall not <br /> p y y 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 /> tion laws of California." [ per <br /> rThe applicant ust call fWr.,, u,,,ed ins ctions.l{Coinpleiedrawing on reverse side,5ignedTitle: Date: I <br /> 1 FOR DEPARTMENT USE ONLY <br /> 1APPlic'11lion Accepted'by '1 �; �C- �s �1 a <br /> Date �. Arts ` <br /> ¢Additional Comments: 9Pit or Grout Inspection by :• ' Date Final Inspection b Date <br /> Oma- ` ' t <br /> r ► <br /> AA <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P O Box 2009, Stockton, CA 95201 f <br /> FEE. Y,-..AMOUNT-DUE---- ' -CK <br /> AMOUNTREMITTED' ^' - <br /> r <br /> NFO CASHT RECEiVED"BY GATE PERMIT'.NO. <br /> • EEH:44.. o^ <br /> H 122e Y11REV.F�xs� h <br /> 137' <br />