Laserfiche WebLink
APPLICATION FOR PERM I T <br /> y SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION � <br /> P O BOX 2009, STWKTON, CA 95201 <br /> (209) 468-3447 U <br /> YEAR FROM PATE !SSUM <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 rA L-- 2'_1� ZZI City E-0,0 1 — Lot Size/Acreage <br /> Owner's Name 1 r Address J, Cf A Phone a4d 33V- <br /> S�rY{�' <br /> Contractor 1,s Address �a License No.6 �a0 Phone G _ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out 'of Service Well 0 <br /> 0PUMP INSTALLATION ❑ SYSTEM REPAIR C1 OTHER �Sori► nritWell <br /> it <br /> oring W <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL. FLO. PROP. LINE i„� *.—, <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �r <br /> ( Trial ❑ Open Bottom 0 Manteca Dia, of Well Excavation Dia. of Well Casing <br /> ; <br /> 8���oJmestic/Private ❑ Gravel Pack 17 Tracy Type of Casing 11 Specifications n <br /> M public Cl Other IJ Delta Depth of Grout Seal Type of Grout U <br /> CI Irrigation Approx. Depth 0 Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction Ia---Wetl Diameter, -37N Sealing Material i Depth it6eZr7 de-,Ct lz= <br /> Depth CO_r _ Piller Material i Depth y <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION fl REPAIR/ADDITION CT DESTRUCTION G iNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will server Residence — Commercial— Other <br /> Number of living units; Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> i <br /> PKG. TREATMENT PLT. D Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. 8 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line { <br /> SEEPAGE PITS 11 Depth Size Number ry <br /> SUMPS LI Distance to nearest: Well Foundation Property Line r5 <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 <br /> Home owner or licensed agent's signature certifies the following "I cartify.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 fallowing: "I rtify that in the performance of the work for which this permit is issued, I shali employ persons subject to workman's compenfs- <br /> tion laws of Calif <br /> The applic trust If r aired inspections. Complete drawing on reverse side. <br /> Signed Title: .,!.f / g/ <br /> IP'rrS�13-u•-'Y-' _ Date: � --- <br /> FO DEPARTMENT USE ONLY <br /> i <br /> Application Accepted by9Data, 7-3_7! .._ Area <br /> Pit or Grout inspection by DataFinal lnspection by Date <br /> Additional Comments: O °Q <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOR 2009, STOCKTON, CA 65201 <br /> Fl <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO, <br /> INFO <br /> . EH 13.24(REV. KOr s SC(s .� ! �ts0 <br /> EH.+14.26 cJ a r+7 <br /> 1 <br /> l _ <br />