Laserfiche WebLink
-APPLICATION FOR PERMIT <br /> SAN JOAN COUNTY,,PUBL I C HEALTH S$RV I CE S ^ <br /> ITVIRONMENTA14;HEALTH_ DIVISIONS <br /> -5� SAN JOAQUIN`;- PHONE (Z 9)468- EO <br /> BOX 2009, STOCKTON, 9A 952 " .`ra. <br /> T EXPIRES 1, YEAR FROM DATE <br /> (Complete in Triplicate) �y , <br /> Applica ion i made to San Joaquin County for a permit to construct and/or install orf ��i~n described. This <br /> application de in compliance with San Joaquin County Ordinance No. 549 and 1862 and the a Tr��'egulations of San <br /> Joaquin Couaty Public Health Services. <br /> wood CitLt Sie/A"c <br /> ob Address - ' <br /> 3,0 4 <br /> r <br /> 1�Owner's Nam <br /> Ad dre i - - - Phone <br /> Aontrattor O .L��'�_ Address LitenseN <br /> No. <br /> Phone <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT r DESTRUCTION ❑ Out of Service Well ❑ <br /> ' PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ l+bnitoring Well ❑ <br /> DISTANCE TO NEAREST`SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELD PITS/SUMPS- <br /> INTENDED USE TYPE OF WE1iedi 101� fV�T �J TI E If MANS �` <br /> n industrial ❑ Open BottomONMMMW.KMTR0 10,L1.0.bi- Dia. of Well Casing <br /> f:3 Domestic/Private �❑ Gravel Pack ❑ T ' Specifications <br /> V- <br /> I'] Public , l71 Other n Dil rECU�h Type of Grout <br /> y <br /> 'I I Irrigation ;F T pprox. Depth I I Eastern Surface Seal Installed by ­zRepsir'Work Done (3 Type of Pump �, H.P. ' ' r State Work Done_ <br /> Well Destiuc[iori f❑'`Weli Diameter* -_. fi' `Seiiina Material A Depth <br /> ' <br /> Depth 'biller Material i Depth -Z <br /> �� <br /> ,T-YPE Of SEPTIC WORK: ,NEW INSTALLATION I 1 REPAIR/ADDITiO DESTRUCTION I I INo septic system permitted it public sewer is r4 <br /> +. ✓ available within 200 feet.) <br /> Installation will serve: Residence Commercial— Other W 00, D - <br /> Number of living uni[s: Number of bedrooms M-661t � �~ <br /> Character of soil to a depth of 3 feet: Water table depth t <br /> SEPTIC TANKS _O Type/Mfg jp ® ' Capacity No. Compartments <br /> PKG. TREATMENT PIT.6-- r r , r, �( r, �(' Method of Disposal <br /> n ; Distance to nearest:V Well �° ' Foundation�' `Property Line <br /> .LEACHING LINE � 'No. 6 Length of lines 0�6 Total le th/slze 1 <br /> FILTER BED .. -,O. Distance to-nearest: Well Foundation f U koperty Lineif 4 <br /> 3 <br /> vv „ <br /> SEEPAGE PITS �I Depth Z Size Num er <br /> SUMPS L1'. Distance to nearest: l0ilell Foundation�-Propertjr Line <br /> DISPOSAL PONDS ❑ <br /> F 1 hereby certify that I have prepared Phis 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 candies the following: "I certify that in the performanc�.of the work for which this permit is issue4,.1-shall not <br /> employ any person in such manner as to become subject to workman's compensation liWs of California "..Contractor's hiring or sub-coritracting 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 opplicarrniVat call for a" iced inspect' ns. Complete drawing on reverse <br /> side. <br /> Signed Title: �1 t+C� a F Date v�r� <br /> : FOR DEPARTMENT USE ONLY /l !S/ �/ •� <br /> f / Ir <br />- _Application Accepted by Date }- Area <br /> t oP Grout Inspection by Date 3 Final Inspet flan by -(-� �- �'� Data <br /> a.�. J � .d <br /> Additional Ca�rrtmanu:' 4 z91� - <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O $oar 2009, Stkn, CA 95201 <br /> i <br /> FEELI, <br /> MOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE E MIT N0. <br /> INFO r <br /> Sk <br /> rfH13.21 <br /> H 1.36 <br /> (REV.1�n5) <br /> E1 <br />