Laserfiche WebLink
M <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY1iPUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL. HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> P O BOX 2009, :STOCKTON, CA 95201 A+,;jDjs zo-24eZ _7-7 <br /> PEMIT EXPIRES 11 YEAR FROM DAIE ISSUB-D <br /> (Complete in Triplicate) ------- 5 I <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 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. /lr v,41 ol,3 r. C>b Q j <br /> Job Address N• 0 City Lot Size/Acreage I <br /> Owner's Name � Ci 74f"Af5775 Address P 1)f Ni Phone 7z7— Z <br /> Contracio <br /> iJ([�G� ress7 �• I�lYJL7ZF,z - -License No.Jr6 Phone i�R/ ' <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C1 DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 07HER�-�. C3U)'L.�NG <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DtSPO5AL FLD. <br /> FOUNDATION AGRICULTURE WELL OTHER WELLf Q! <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS /Pf;rune Q y <br /> L1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing rS0er:4M0f1&As <br /> I'l Public 1-1 Other n Delta Depth of Grout Seal TMBe­* f__ W , <br /> I i IrriOauon —.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H,P. State Work DoneEdw <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth io <br /> Depth Filler Material is Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> I <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. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> I <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll 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 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 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 signatur <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 must call for all r uired inspections. Complete drawing oh reverse side. <br /> Signed X 1 Title: w6• 6F0Go64S% Date: :in <br /> OR ARTMENT USE ONLY �qr <br /> Application Accepted by P15Date ( 0 Area <br /> Ci <br /> II Pit or Grout Inspection by Date Final Inspection by Date�ZS <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental-Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CIC <br /> INFO CASH RECEIVED BY DATE PERM17'NO. <br /> t EH 13.24 fREV.I i h 51 <br /> EH A-?8 <br />