Laserfiche WebLink
4 t V APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM 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 vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin countyPublicHealth Services. tt�� <br /> zOt0S W SP.V1�1 atW1I✓1 t fD��DY 1 Ve City ���� Lot Size/Acreage <br /> Job Address <br /> ,v C��GG �a <br /> Address f ��LY'� 1*14APhone O— Z— <br /> Owner's Name �i2vj'Dn !/J� �jC q <br /> Contracts j �(,���r/�</ Address O <br /> � q P144 1;11, 1.0 License No.T02�f� Phone L6��' <br /> Service well 0 <br /> TYPE OF WELL/PUMP: N WELL WELL REPLACEMENT n DESTRUCTION O Out of <br /> Well <br /> ....., PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O <br /> I OOTAN O TO NEA tUT- SEPTIC TANK 7 100- SEWER LINES 1O�r OTHER LFL D PROP.TS//SUMPS _ <br /> FOUNOATION 7 1 D� AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f/ <br /> n Industrial O Open Bottom O Manteca Dia. of Well Excavation 11- Dis. of Well Casing <br /> f71 Domestic/Private ❑ Gravel Pack7 O Tracy Type of Casing r V c- Specifications <br /> I'1 Public A<01her fl Delta Depth of Grout Seal �-0/ Type of Grout Fea %A <br /> I I Irrigation 3.'t�Approx. Depth I I Eastern Surface Seal Installed by fil44D <br /> Repair Work Done L3 Type of Pump H.P. Stat qq Work Doe_ <br /> Well Destruction O Well Diameter 2 u <br /> Sealing Material & Depth N t / <br /> & 140nr'{`srew Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: 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. O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.O Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING UNE CI No. i Length of lines Total length/size <br /> ': - Foundation Pfopeny Line <br /> WOO Foundation Property Line <br /> �. 0 <br /> 1 hereby"reify that 1 hew prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and nptrlations of the San Joaquin County <br /> Home owner or licensed pant's signature cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any Berson in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub.contracting signature <br /> unifies the following:"1 terrify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compen". <br /> tion laws of California." <br /> The applicant must call for ON required inspections. Complete drawing on reverse side. <br /> Signed X Title: <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> . EM 13-2E 111EV.I/e s! <br /> EM 1E•x <br />