Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUN'T'Y PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL IiEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> RMIT EXPIRF&S I MAR PROM-RATE ISSUED `�� evt I`~� <br /> (Complete in Triplicate) me,/ /, <br /> Application is hereby made to San 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 Address S 7 G JZ p2>ti i ll City 0 Lot Size/``Acreage <br /> Owner's Name ��, if Q 0 C�W'Add(ess +a- Phone � 1 <br /> Contractor rla //Y-,-/ bailli;q Address P n 194-!%�)L (et /T License Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service We11 ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR, OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK !&:19 SEWER LINES DISPOSAL FLD. _ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELLb_j PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT ONS , o <br /> fl Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing <br /> U Domestic/Private CI Gravel Pack ❑ Tracy--Type of-Casing Iq <br /> Specifications <br /> kli?,Iff <br /> Pa fic is Other 0"Delta Depth of Grout Seal f Ty of Grou��'� <br /> ation 906—' Approx. Depth C] Eastern Surface Seal Installed by <br /> ir.Work Done U Type of Pump �; �WP, ! - - State Work Done <br /> Well Destruction 0 Well Diameter ! Sealing Material i Depth <br /> ! Depth Filler Material 4 Depth r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION CI REPAIR/ADDITION CI DESTRUCTION F-I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> f t <br /> Installation will serve: Residence Commercial �. Other I� <br /> Number of living units: Nurhbe�of bedrooms r <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments' <br /> PKG.;-TREATMENT PLT,0 Method of Disposal <br /> Distance to nearest: Well Foundation. Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> t <br /> SEEPAGE PITS ( I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation I Property Lina <br /> DISPOSAL PONDS ❑ 1 <br /> I hereby cartify that I have prepared this application and that the work will be done in accordance with San S6aquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County - 'ej i <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 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 compensa- <br /> -'tion lays of Californla." -- �- <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> a F'—. Date: LCa <br /> 1 4 r R DEPARTMENT USE ONLY <br /> Applic n-' pled by Date Area 1 <br /> Pit r rout I Pachon by:d—��^ -- - Date Final Final Inspection b;L—> Date I l <br /> _s <br /> Add I <br /> Co <br /> Applicant - Return all copies to, SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES v <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 98201 <br /> -7K 11 <br /> e/,NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE +PErR�MIT"NQ. <br /> + EH 1,' iREV.iin3i 7' C_h0A%X_ <br />