Laserfiche WebLink
-APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRE I YE <br /> AR FROM DATE- _03VED <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 i <br /> application is made in compliance vith.San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 1 Cr City -pig i 1,pt Size/Acreage <br /> Owner's Nam r t, Address 17 � Phone <br /> CUnlydCtO(,JZ License Noe hyW _Phone 3663f:33 <br /> ..� Address m• <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT 171 DESTRUCTION O Out of Service Well 0 <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well. ❑ <br /> DISTANCE TO NEAREST:_SEPTIC TANK I SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOU 110 f AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial 4r ❑-Open Bottom: 0 Manteca '"--r Qia,. of Well Excavation Dia. of Well Casing ` <br /> Cl Domestic/Private _ ❑ Gravel Pack*1 0 Tracy TypeoCarsing_. Specifications <br /> i'1 Public 17 Other n pelta Depth of Grout Seams i'""*^� A Type of Grout <br /> I 1 Irrigation r..,_Approx. Depth 1 I Eastern Surface Seal Installed by <br /> Rep,�ir Work Done , 0 Type of Pump H.P. State Work Done, <br /> Well Destruction O Well Diameter Sealing Notarial i Depth i <br /> Depth Tiller Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I 1 INo septic system permilted if public sewer,is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ OOtthe�r, <br /> Number of living units-__:__ - Number of roams <br /> Character of Soil to a depth of 3 feet: Water table depth. !� <br /> SEPTIC TANK. lf7 Type/Mfg Capacity No. Compartments ] <br /> PKG. TREATMENT PLT.p ' i Method of Disposal .33� <br /> Distance to nearest:lr• Well Foundation' Property Line <br /> LEACHING LINE V- No. 6 Length of lines U � -_- R Total length/size cS / <br /> FILTER BED ❑ Distance to nearest: Well Foundation -7% Property Line <br /> 1 X . <br /> SEEPAGE PITS ISI' Depth $t Size 3 *. Number <br /> SUMPS LI Distance to nearest: Well Q 4) Foundation Property Line <br /> DISPOSAL PONDS O <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, anc <br /> ! <br /> rules and regulations of the San Joaquin County �" <br /> Homs owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall no <br /> employ any person in such manner as to become subject to workman's compensation laws of California.",Contractor's hiring or sub-contracting signaturk,- <br /> esrtifies the following: "I certify that in the performance of the work for which this permit is issued, I @hall employ persons subject to workman's compenss- <br /> .tion laws of California." i h <br /> The appf t must call for all aqui inspections. Complete drawing on reverse side. j <br /> Signed Title: ��� - ~Date: .07-�-/ Z� <br /> } *� R EPARTMENT USE ONLY . <br /> Application Accepted by . _ Date ___ �-�.-. - _ Arcea 2+ <br /> or Grout Inspection by !T: Z�� Data 4'LFinal Inspection b ` oats <br /> Additional Comments: <br /> I � <br /> Applicant - Return all copies! to: San Joaquin County Pub ic'Health Services b <br /> Environmental Health Permit/Services �- <br /> 445 N San Joaquin, P O Boz-2009, Stkn, CA 95201 <br /> INFO <br /> EEE AMOUNT DUECK <br /> AMOUNT REMITTED CASH 'RECEIVED By DATE PERMIT-NO. �(D` <br /> . EFS 13-24 tlIEV.ISR 54 <br /> EM 14-M (J <br />