Laserfiche WebLink
APPLICATION FOR PERMIT t. <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> MIT EX _RES 1„YEAR `ROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application Is hereby made to San Joaquin County for a permit to construct and/or ineta7.1 the vork herein described. This <br /> application ie made in compliance vith San Joaquin County Ordinance No. 544 and 1662 and the Rules and Regulations of San <br /> Joaquin <br /> b uin Count Public <br /> �Health Services.. ,( <br /> i <br /> JoAddress � 04C V\1 Lot Size/Acreage <br /> — -_ <br /> Owner's Name VA L 11ei Address 4 s5- leu T Phone ;PSA>9 -93 J <br /> r SIJ/ f�� ,p r <br /> Centractor� w r * Addres's� I&L=�..^5ir__,. ILS! License No ?Q74755,52 Phone~ -- /&k <br /> TYPE OF WELL/PUMP: _ NEW WELL ❑ t WELL REPLACEMENT DESTRUCTION K Out of Service Well ❑ <br /> PUMP INSTALLATION�❑ ( LL SYSTEM REPAIR O OTHER ❑ Monitoring well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES A0 4P7 oe DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F f <br /> fl Industrial 0 Open Bottom ❑ Manteca Die. of Well Excavatio Dia. of Well Casing 19 <br /> QomesuclPrivate KGravef Pack ❑ Tracy Type of Casing Specifications <br /> M Public ' is Other O DeltaDepth of Grout Seal f Ty of utr <br /> r <br /> C! IrriUation —Approx. Depth © Eastern Surface Seal Installed by i <br /> Repair Work Done U Type of Pump - H.P. State Work Done <br /> Well Destruction 0 Well Diameter 4 Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION❑ REPAIRIADDITION Ll DESTRUCTION G lNo septic system permitted if public sewer is <br /> * available within 200 feet.) <br /> Instillation wi!! serve: Residence____. Commercial�, Other i <br /> Number of living units: Number of bedrooms r <br /> Ilk <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. ❑ _ t Method of Disposal <br /> Distance to nearest: Well Foundation Property Line r <br /> LEACHING LINE `, ❑ No. & Length of lines Total length/size <br /> FILTER BED _ n Distance to nearest: - Well Foundation Property Line <br /> SEEPAGE PITS i II Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Lina <br /> DISPOSAL PONDS- _ ❑ (. t <br /> I hereby certity that l 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 ; j <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-contracting 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 laws of California." <br /> The applicant usI call for all required inspections. Complete drawing on reverse side. j <br /> f! <br /> Signiid C- Title: .1.�nl lis yf Date: Z <br /> FOR DEPARTMENT USE ONLY i <br /> Applica ' ccepted by Date ��� a �Y <br /> Pit Grout napeetion byU Date I 1-3U-�;J Final Inspection b Data , <br /> rov! e r <br /> Additional Comments:' `� �Y��-°p-Q too' C�-'s-)sucIr;dn ")elx 0,-, w�TZ.u�•� � �s �h'�., -3 <br /> Applicant - Return all copies to: SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 995 H SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 98201 <br /> FEE <br /> )NFO AMOUrNNTTt DUE AMO�U/TQ,RfEEMITTED CASH EiVED BY DATE PERMIT•N0. <br /> x <br /> . EH 13-74 1REV.1/415) / /i �% t��fJ� [/ ty, (/ / <br />