Laserfiche WebLink
' r <br /> APPLICATION FOR PERMIT f <br /> f SAN JOAQUIN COUNTY PUBLIC EURALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ^ <br /> P O BOX 2009, STOCHTON, GA 95201 1yr <br /> (209) 468-3447 <br /> Y R <br /> (Complete in Triplicate) <br /> II <br /> Application is hereby mada;� an Joaquin Count n County Ordinancermit to nIioru5�9ct aandol8d28and LheeRulea an dvork eRegulations in dof Bans <br /> application is made i carp <br /> Joaquin County Public Health Services. �/, -, <br /> �•f ;� r�� �/�iVyLot 8isa/Acreage <br /> J City J s <br /> Job Address �CIlne �r <br /> �Z rZ rr;-1 Address <br /> Owner's Name f-rr% <br /> �, �rv/��t License No. rPhone ; <br /> Contractor 't/` ' C ress <br /> MENT CJ DESTRUCTION L Out of Service <br /> NEW WELL ❑ WELL REPLACE <br /> Well ❑ <br /> TYPE OF WE OTHER ❑ t+tonitori Well <br /> ''i SYSTEM REPAIR ❑ <br /> PUMP INSTALLATION ❑ ' DISPOSAL FLD.• PR NE <br /> DISTA-NZE TO IVL�RET' EPT1C TANK �,.�� SEWER LINES �;--- — Ifs/SUMPS <br /> FOUN -- -- <br /> AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL P AREA CONSTRUCTION SPECIFIC Dia. of Well Casing <br /> ❑ Open Bottom ❑ Manteca of Well E ton <br /> Cl Industrial Casing Specifications <br /> U Domestic/Private � ❑ Grave! Palk ❑ Tracy rout Seal _ Type of Grout <br /> � Depth of G <br /> - D R <br /> T:1 Public L1 Other , ❑ <br /> Il gpflro„` �Q Eastern Surface Seal installed by <br /> C3 Irrioation H.P. State Work Done <br /> Repair Work Dona V o Pump r ' <br /> , <br /> a� Sealing Material L Depth <br /> Well Destruction ❑ Well Diameter Biller Material M Depth r <br /> -Depth"L. i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIse <br /> ON L7 REPAIRlADDITION Cl DESTRUCTION GI eNailablpeiw within 200 feelc system .) if publisewer is <br /> installation will serve: Residenca!� Commercial— Other S <br /> _ <br /> Number of living,units::, ' '` Number of bedrooms / , Water table depth <br /> C r <br /> Character of sot!to a dap h of 3 foot: No, Compartments <br /> _ �:---�-�' ik - Capacity- - <br /> SEPTIC TANK. ❑ °Type/Mf9 s- Method of Disposal <br /> PKG. TREATMENT PLT.❑ , Property Line <br /> Distance to nearest: Well _. Foundation <br /> 711 <br /> Total length/size <br /> LEACHING LINE L`1 No. & Length of lines /Vs Foundation � Property Line �— <br /> FILTER BED n �lDistance to nearest: Well �� <br /> r <br /> Number <br /> SEEPAGE PITS I I Depth 2 - Sire <br /> / ! �Q Foundation Property Line o <br /> SUMPS L1 Distance•,to-nearest:---� Well ��— <br /> DISPOSAL PONDS ❑ i- -, <br /> I hereby certify that Lha've prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and <br /> i rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "l certify that in the performance of the work for which this permit is issued, i shall not <br /> l 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 shaii employ persons subject to workman's compensa- <br /> tion laws of California," <br /> The applicant mus 14or all r ed inspections. Complete drawing on reverses ids. -2—:2r <br /> _ ,. - .-_.. -- .,.- �• Title; Dere: <br /> Signed i <br /> j� FOR DEPARTMENT.U.SE ONLY <br /> Area <br /> Application Acceptad by y <br /> -.. ,.�- -- --., _,�•-Date 2 i t �. w Y <br /> _ Date <br /> ar Grout Inspection by �-'� 0 'r. -..-�- Date�-- Final Inspection by� - <br /> i <br /> Additional Comments: <br /> Applicant - Return sllcopiea to: SATE JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> CK RECEIVED BY DATE PERMIT'NO. <br /> FEE AMOUNT OUE AMOUNT REMITTED CASH <br /> /�//' /y � <br /> a EH 13.241 RINFO EV.l lw 61 ll /l vv `•'r— C'� a 471— <br /> JH <br /> 7 +EH 14.20 <br />