Laserfiche WebLink
APPLICATIONe FOR PER I <br /> . <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL AEALTH DIIISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-w3447 ' <br /> •- PERMIT EX IRES I YEAR <br /> �)QDy W! {Complete in Triplic `te} <br /> Application Se hereby made to S Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in etxspliance 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 C'Amc4-i Y 2— City X0171 Lot size/Acreage /__1Z3 <br /> Owner's Name Towl'i Address �O. X AI y W�oor7���__G9 Phone 3� "•�� Q I <br /> Contractor 77i� License No.�N Git'E Phone 2 _y <br /> �A �/Nrt Address Q <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 0TH R Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. g 1t tNuF` <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSlSUMP c. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavatid`'n Dia. of Well Casing <br /> C! Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing �� Specifications <br /> M Public 1.1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> — <br /> 0 Irrigation —Approx. Depth ❑ Eastern Surface Soul Installed%y <br /> Repsir Work Done U Type of Pump H.P. 1,State Work Done 'y 6e <br /> Wall Destruction 0 Well Diameter Sealing Material i Beeth <br /> Depth Filler Material i Depth 11 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITION 0 DESTRUCTION 0 (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial T 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 aM No. Compartments <br /> PKG. TREATMENT PLT. G'1 � Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> �M <br /> LEACHING LINE Cl No. 8 Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation IM Property Line <br /> SEEPAGE PITS I I Depth Size filumber <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <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 Sen Joaquin County <br /> Home owner or licensed agent's signature cartifies the following: "I 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 talifornia," Contractor's hiring or sub-contracting 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 applicant owst call for all required inspections. Complete drawing on reverse side. <br /> Signed �95P- Title: NASSDate: <br /> ^ to I <br /> FO DEP RTMENT USE ONLY, <br /> Application Accepted by Datec Area v J <br /> Pit or Grout Inspection by Date Final Inspecti In by } 1 Date ! <br /> Additional Comments: e0 e 4 AJ <br /> Applicant — Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES �� <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> 4FEE <br /> v <br /> INFO AMOUNT DUE AMOUNT REM(�iTTTED CASH RECEIVED BY DATE /1 1lPER1MI7 N0. <br /> r EH 1`'2411MV.1/n Sl �� .O 1�\3 —�. II 7'� • •q �11 �1��� <br />