Laserfiche WebLink
e; <br /> APDL'CATION FOR PERM I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> i <br /> (209) 468-3447 <br /> 'PL_,IV,0 Pepa.b t: YEAR PROM DATE- IMED <br /> (Complete in Triplicate) <br /> Application Is hereby made to Sao,Joaquin County for a permit to construct and/or install the work herein described. This <br /> application Is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job AddressK552 Le -.. 4 f�� City Lot 31ae/Acreage <br /> Owner's Name df Address . one <br /> Canlracfor t, G'-YAddress 4 License No. J`7�� 0--Phone 4 <br /> TYPE OF WELL/PUMP: NEW WELL ❑» WELL REPLACEMENT M DESTRUCTION CI Out of Service Well 0 <br /> PUMP INSTALLATION 0_..__41., <br /> �.,r_, ySYSTEM REPAIR}tT_ OTHER ❑ Monitoring Well {� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER SEWER LINES DISPOSAL FLD. _" PROP. LINE <br /> FOUNDATION ' t AGRICULTURE WELL, -OTHER WELL L � PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREAS CONSTRUCTION SPECIFICATIONS. ' <br /> Cl Industrial 0 Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing <br /> 1),f lomestictPrivate 0 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 0 Public I'1 Other ' 0 Delta Depth of Grout Seal 4 Type of Grout <br /> G Irrioation Approxi r Depth Easter Surface Seai Installed by <br /> Repair Work Done Or Type of Pump H,P. State Work Don <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material i Depth <br /> 0 <br /> Depth .r Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION'17;REPAIR/ADDITION 0 DESTRUCTION 0 (No septic system permitted if public sewer is <br /> available within 200 feet-1 <br /> `� .-. <br /> Installation will serve: Residence_: Commercial_ Other <br /> Number of living units: Number of bedrooms x <br /> Character of soil to a depth of 3 feet:i l T` Water'.table depth <br /> SEPTIC TANK. ❑ Type/MfgA t ' t Capacity No. Compartments <br /> PKG, TREATMENT PLT. 0 ;� � t, Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> 4 �1 <br /> l LEACHING LINE ❑ No. $ Length of lines Total length/size <br /> FILTER BED n Distance to�nearest: Well Foundation Property Linel <br /> SEEPAGE PITS I I Depth Size Number <br /> ;.a <br /> SUMPS LI Distance tb'nearest- Well Foundation Property Line <br /> DISPOSAL PONDS 0 1 <br /> I hereby certify that I have prepared this:ipplication and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the Sen Joaquin lCounty <br /> Home owner or licensed agent's signature.canities the following: "I certify that in the performance of the work for which this permit is issued. I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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 compe sa- , <br /> tion laws of California." <br /> The op us call for all required in>� ctions. C plate drawing on r rse side. <br /> Signed ' TiUe: �� Date: <br /> iFOR DVPARTMENT USE-ONLY- <br /> Application Accepted byfiAaa e�www Date I ILA_ Area <br /> Pit or Grout Inspection by Date - Final Inspection by Date z� <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> tENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES (�( <br /> 445 H SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 95201 <br /> tN E AMOUNT DUE AMOUNT HEMiTTED GASH CK I RECEIVED BY DATE PERMIT'NO. V <br /> . EH 13 24 IREV.It1%51 y"l\ ,do '�'" ,"�✓R� 1 e�`"L"'L`"Cl.� d'"`J i <br /> 4 t <br />