Laserfiche WebLink
APPLICATION FOR PERMIT <br /> 4 " <br />¢ SAN JOAQUIN CCOUNTY PUBLIC REALTHCSERVICES <br />+4w t ! ENVIRON1dENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)'468-3420 , <br /> P 0 BOA 2009, STOCKTON, CA 9501 <br /> -._. PERMIT EXPIRES 1 YEAR FROM DATE IS$UEU <br /> ` (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin Coun%y for a permit to construct and/or install-the work herein described. This <br /> application Is trade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of.San <br /> Joaquin County Public Health Services. �� P� <br /> /BG�J <br /> �� <br /> sJob Address, 0 ce- <br /> .� n�ER ��to �` R� City Lot Size/Acreage <br /> Owner's Name <br /> SL �- Address r �.E.i1' �•Phane---- - s <br /> Ste%rn s �I C�/ 7 'Z�b` ,/. <br /> / r J � <br /> Cont actor Address 96 Vaf License No. I Z Phone ; t <br /> TYPE OF WELL/PUMP. NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ . <br /> PUMP INSTALLATION C7 t <br /> SYSTEM REPAIR ❑ OTHER p Monior ng rweh,-L�? . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINED ' ` <br /> FOUNDATION c AGRICULTURE WELL �C OTHER WELLPITS/SUMPS <br /> INTENDED tJSE­ -k TYPE•OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial Open Bottom ❑ Manteca; Dia. of Well Excavation �� Dia. of Well Casing <br /> 5 Domestic/Private O,Grivel Pack - -+ C7 Tracy f Type of Casing _4 Specifications �. <br /> I'l Public is Other t F1 Delta Depth of Grout Seal n' Type of Grout_ ! !T <br /> I I )irrigation T _.Approx. Depth I I Eastern+` Surface Seal Installed by ` `t <br /> RepairtWork Donee B Type of Pump H.P. State Work Dona <br /> Well'Destruction ❑ WelI star I Sealing Material Depth 1. <br /> pth I Filler Materia pth F <br /> STYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAMIADDITION i I DESTRUCTION I I INo'septic'sysIsm permitted if public sewer is U <br /> available wahm 200 feet.) { <br /> Installation will serve: Absidence_ Commercial_ Other r <br />,I Number of living units: Number of bedrooms a <br /> Charactet•of soil to a depth of 3-feet: Wats ble.depth ) # <br /> .SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> t PKG. <br /> TREATMENT-PLT,. 1 ` 9 1 Method of Disposal t <br /> Distance is nearest: Well Foundation Property Line <br /> ►, LEACHING LINE ❑ No. & Length of lines Total length/size I <br /> FILTER BED ❑ Distance to Weare . 1Netl Foundation Property Line �F ' <br /> SEEPAGE PITS .I 1 Depth Size Number k <br />,f ^ <br /> SUMPS Ll Dis nce to nearest; Well Foundation Property Line ; <br /> DISPOSAL PONDS ❑ <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 /> 'rules and regulations of the San Joaquin County y <br /> 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 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-coWactirag-signature <br /> cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to work an's compensa- <br /> ,tion laws of California." l FFfff <br /> The applicant or all required -nspectio ate drawing on reverse-side.. } f> <br /> Signed X �+ Title: Dater i <br /> FO DEPARTMENT USE ONLY <br /> Application Accepted by <br /> { Date v Area 1 <br /> Pit or Grout In by Data Final Inspection by to `�ti• <br /> i Additional Comments: <br /> L Applicant - Return all copies to: •San Joaquin County Public Health � l <br /> Services, Environmental Health Permit/Services_— <br /> a ---- . _ —­1601fE.-Hazelton-Ave:;"P"'OrSaz X009;Stock�on,�CA-95201, - <br /> "SEE_.,— OUNT DUE AMOUNT REMITTED "-CK 11 CAS.F1 1�RECEIVER t3Yi �,DATE PERMI7•NO. <br /> INFO97 <br /> g <br /> Ell <br /> H1426tA t/n51 CJry LJ � +�^F v <br /> A - <br />