Laserfiche WebLink
APPLICATION FOR PERMIT <br /> S. JOAQUIN COUNTY PUBLIC HEAL1 SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 20091, STOCKTON , CA 95201 <br /> ( 209 ) 468 - 3447 <br /> PP>�IT BApIRES 1 YEAR FROM DATE ISSUED <br /> ( Complete in Triplicate ) <br /> Application is hereby mada , to San Joaquin County for a permit to construct and/ or install the work herein described . This <br /> application is made in compliance with Ban Joaquin County Ordinance No . 549 and 1662 and the Rules mad Regulations of San <br /> Joaquin County Public Health Services .. <br /> �/ <br /> Job Address / "1 g E454 C�/! G r 4 %Vr W4 le City s-/'ec k �y ✓I Lot Size/Acreage / 145 ox / .Z5mr <br /> Owner's Name Dgr roe 7L ro I � Inc_ Address 3gT0 Z' l e'd ~ r n0 Phone <br /> _ Firs+rw f <br /> Contractor X le c A Address c License No. 596 S H S Phone -d <br /> TYPE OF WELL/ PUMP, NEW WELL 0 - WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST : SEPTIC TANK SEWER LINES DISPOSAL FLD . PROP . LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS / SUMPS <br /> _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSof q <br /> „ <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia . of Well Excavation Dia. of Well Casing <br /> U Domestic/ Private QI Gravel Pack ❑ Tracy Type of Casing PVL Specifications <br /> M Public fl Other ❑ Delta Depth of Grout Seal 45' Type of Grout 'v A••r } rcrrarn. <br /> M Irrigation jai Approx , Depth n Eastern Surfice Soul Installed by Fr c / / c• 4 - - - <br /> Repair Work Done L3 Type of Pump H . P . State Work Done _ <br /> Wall Destruction O Well Diameter Sealing Material A Depth <br /> Depth Tiller Material a Depth <br /> TYPE OF SEPTIC WORK : NEW INSTALLATION ❑ REPAIR / ADDITION CI DESTRUCTION G INo septic system permitted if public sewer is <br /> available within 200 feet . ) <br /> Installation will some: Residence — Commercial _ Other <br /> Number of living units. _ Number of bedrooms <br /> Character of sag to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/ Mfg Capacity No. Compentrtents <br /> PKG, TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> j <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS LI Distance to nearest: WON Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, send <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shell not <br /> employ any person in such manner as to become subject to workman' s compensation laws of California . " Contractors 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 call for eN r uirid " lip eons. Complete drawing on averse side. y� 7 <br /> Signed TitN: ��• ,% ` c f // r4N4,eve Dau: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Ares <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> '7 <br /> Additional Comments: — <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 /> * FEE AMOUNT DUE AMOUNT REMITTED CK it RECEIVED BY DATE PERMITNO, <br /> NFO CASH <br /> • EN 13024 IREV. " 015) <br /> EN 14•aa <br />