Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> MWIT BUIRBS 1, YEAR ]PROM! DATE ISSUED <br /> (Complete in Triplicate) <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 / �_,L„��_ QST `'� GrZ/ r City Lot Size/Acreage <br /> Owner's Name l/.�1f>r1 LAC r+ t Aft f1e) i Address .f9 ` / 4/ S, St g I 'r Phon?L9 5r 3�-'3 1?s-1 <br /> ConlraUor Q TAddress License No. Phone <br /> TYPE OF WELL/PUMP. NEW WELL ❑ W L REPLACE NT ❑ DESTRUCTION Cl Out of Service Well 0 <br /> PUMP INSTALLATION ❑ STEM EPAIR C} OTHER ❑ Monitoring well <br /> DISTANCE TO'NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE L OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA C SF CTION SPECIFICATIONS <br /> CI Industrial ❑ Open Bottom 0 Manteca in- of We Excavation Dia. of Well Casing <br /> r <br /> U Domestic/Private L7 Gravel Pack 0 Tracy Type of Cas_1 Specifications <br /> Q Plrblic f.1 Other ❑ Delta Depth of Grout sal Type of Grout <br /> G G ErnUation ^..Approx, Depth fl Eastern Surface Seal insta d by <br /> Repair Work Done 0 Type of Pump P. State Work Done _ <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth }Tiller Material & Depth <br /> T OF SEPTIC WORK: NEW INSTALL.ATiON F REPAIR/ADDITION 0 DESTRUCTION 0 fNo septic system permitted if public sewer is \ ' <br /> ,` available within 200 feet.) V <br /> Installation will serve: Residence 1. Commercial— Other <br /> Number of living units. . Number of bedrooms -- <br /># Character of *oil to■ pth of 3 feet: 94 Q Water table depth -70 <br /> SEPTIC TANK Type/Mfg Capacity S4 No. Compartments 2- <br /> t KG. TREATMENT PLT, ❑ r Method of Disposal <br /> Distance to nearest: Well �_ Foundation 2 ) Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> E FILTER BED 0 Distance to nearest: Well Foundation �-�� Property Line �� h <br /> y r <br /> t SEEPAGE PITS )e Depth S Size + T _ Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ ` - <br />? 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 <br /> Home owner or licensed agent's signature certifies the following: 1 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 perlormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." - ° - <br /> k T s applicant must call for all required inspections, Complete drawing on reverse side.!/4L Title: E rQ��t- Date: <br /> Signed}L- _ �^ ,rr�tc,� ��— <br /> F _ �, — <br /> �+ OR DEPARTMENT USE ONLY <br /> Application Accepted by .. �,r,��.4 ''�" _-7--l - Date <br /> Pit or Grout Inspection by Date Final Inspection by­1015551 l'.e ___ _ Date�a v <br /> Additional Comments, <br /> Applicant - Return all copies to: BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 85201 <br /> FEE <br /> INFO MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> . EH 13,24IREV.I/A57 - J (�'_n e ) <br /> r . <br />