Laserfiche WebLink
... – w <br /> "� <br /> APPLICATION FOR PERMIT + N ..t k <br /> $" <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES iA <br /> ENVIRONMENTAL HEALTH DIVISION <br /> } q� 2 2 <br /> P 0 BOX 2009, STOC%TON, CA 95201 pE�M �TAf L <br /> { (209) 468-3447 � ,VICS TLj <br /> ' 2-EMIT EXPIRES 1 YTsARR PRAM DATE ISSUED <br /> (Complete in Triplicate) �' <br /> Application is hereby made to San;Joequin County for a Permit to construct and/or Install the 'work herein described. This <br /> application is made in cowliance:vith San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address ' � r � City .. Lot Size/Acreage <br /> Owner's Name — � Address eo . 3-2 Phone <br /> Contractor ,!/ - Address 4� z !;�K3 ® icense Na. a- Phone f <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ . DESTRUCTION Cl Out of Service Well 0 <br /> PUMP INSTALLATION C� SYSTEM REPAIR 11� OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 11 Ind trial ❑ Open Bottom_ ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> zomestic/Private Cl Gravel Pack . n Tracy Type of Casing Specifications <br /> ❑ Public 1:1 Other p Delta Depth of Grout Seal Type of Grout <br /> 0 Irrigation Approx. Depth L] Eastern Surface Seal Installed by <br /> Repair Work Done P-11,—Type.of Pump � H,P, State Work Done <br /> Well DestructionO Well Diameter Sealing Material k Depth <br /> Depth ) Piller Material 4 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDIT€ON 0 DESTRUCTION ❑ INo septic system permitted if public sewer is <br /> I available within 200 feet.) <br /> Installation will serve: Residence rCommsrcisl— Other <br /> Number of living units; Number of bedrooms <br /> Character of Boil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK, ❑ Type/Mfg +l Capacity ^_ I <br /> No. Compartments <br /> PKG. TREATMENT PLT. C7 � Method of Disposal <br /> Distance to nearest: Well Foundation Property Line `f <br /> j by <br /> LEACHING LINE ❑ No. ii Length iof lines Total length/size i <br /> s. FILTER BED C-0 Distance to nearest: Well Foundation Property Line ;! <br /> SEEPAGE PITS 11. Depth —L—SizeNumber <br /> SUMPS LI, Distance to neiaresv WOR FoundationPro <br /> DISPOSAL PONDS p �. Penh Line <br /> i' <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 /> rulas and regulations of the San Joaquin County ,r. <br /> Home owner or licensed-agent's signature ceitifies the following: I certify that in the performance of the work'for which this permit is issued, Iishall not <br /> employ an <br /> p y e ppiowing.such manner as to become subject to workman's compensation taws of California," Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify in the performance of the work for which this permit is issued, I shall ern loy persons sub Pe <br /> tion laws of California." �' -' •r�- �» -----_ _.._ _.,,,• .. _ �� � a ject to workman's com nae• ' <br /> T.he applicant must call a required igspe, tions. Complete drawing on r I"tide: <br /> Signed ¢ Title: r ,����fi +r�I 1 <br /> Date. <br /> `"FOR DEPARTMENT USE ONLY <br /> Application Accepted by pate # e !f� <br /> Area <br /> t 1 <br /> Pit or Grout inspection by Date Fina! Inspection by <br /> Data <br /> Additional Comments: � 1 <br /> Applicant – Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES W <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, 8TOCKTON, CA 86201 <br /> FEE MOUNT DUE 'AMOVNT REMITTEq CK RECEIVED BY <br /> INF�Oj r ` CASH DATE PERMIT NO. <br />. EH r3.21'11tEV,1/"51 �r/ !�- 00 <br /> fH X428 !"� G VVVVVV <br />