Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAIF JOAQUIN COUNTY PUBLIC IIF.ALTII S p �, -- <br /> ElYVIRONIEgvTgl, AFALTg DIVISIO �nn <br /> 445 N SAN JOAQUIN, PHONE (209)468T3&#-... XM <br /> P O BOX 2009, STOCKTON, CA 952 <br /> QAC# <br /> PERMXTEXPIRES -I YEAR FROM DAT! <br /> S <br /> {Complete is Triplicate) tI # 7� <br /> [� APPlication in hereby awe tp San Joaquin County for a permit to construct <br /> 11 pPlicatlon is made in ccmpliartte With San Joaquin Count and/or Install the vork herein deecrlbed. This <br /> ` Joaquin County Public Health Service@. Y Ordinance So. 549 and 1862 and the Rules and Regulations of San <br /> Job Address I 1.� <br /> ` ��� City' ULk'� Lot files/Acreage <br /> :I Owner's Name i1 'pp y f �S ;�34 1—moi -31a <br /> Address I • C i .yt� 4� <br /> r — ,tUI_ Phone <br /> Contract ti►rtkiS_ i.c at [11 Address V? i l <br /> TYPE OF WELLIPUMP: License No d U �Z Phan <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑Out of Service Yell ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ❑ <br /> QISPOSAL Ftp. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER W i <br /> INTENDED USE PITS/SUMPS ` <br /> TYPE OF WELL PROBLEM AREA <br /> L7 lnduEND '��- CONSTRUCTION SPECIFICATI <br /> ❑Open Bottom ❑Manteca Die.of Wall Excavation <br /> j: Cl PomesriclPrivata 1�®f Well Casing \ <br /> a Cl Gravel Pack ❑Tracy Type of Citing <br /> !'1 Public Ll Other ficatioru _ <br /> �1 Pelta �� <br /> Depth of Grout Seal ��+�T <br /> I I Irrigation ApprosSurface Seal Installed <br /> • Depth I I Eastern �'�CT�'paNQf�rovt "�� <br /> U T <br /> Repair Work Done U Type of Pump H.P. . <br /> ..i Wall Destruction ❑ WON Diameter Sealing Material i Depth IY7T;Le I <br /> Depth Tiller Naterial i Depth <br /> - TYPE OF SEPTIC WORK: NEW INSTALLATION I I 1: p! DESTRUCTION I I INo septic system <br /> permitted if public saw*r is <br /> Installation will serve: <br /> Residence�/ available within 200 feet.! <br /> Commercial Other <br /> �I Number of living units:�_ Number of bedr ms­73 <br /> Character of soli to a depth of 3 fast:. <br /> SEPTIC TANK. ❑ T - Water table depth OCA j <br /> YwlMfg' .:t _ Capacity Compartments <br /> PKG.TREATMENT PLT.❑ No.Compa <br /> Distance to nearest: Well Method of Disposal <br /> - Foundation Property Line <br /> ���✓✓✓ r i <br /> LEACHING LIRE �y No.d Length o!linos. -�F: SEEPAGE <br /> FILTER BED / _ ! Total length/sire X r I <br /> 0 Distance to nearest; Weft Foundation— `0 - Property <br /> perty <br /> 'I !r <br /> SEEPAGE PITS �/ f s <br /> J"�DePEh <br /> SUMPS Sime Number . <br /> CI Distance to nearest: Wellr f ; <br /> DISPOSAL PONDS ❑ ? Foundation 1 O r l Property Lina r i <br /> i <br /> I haraby eenprepared this apPify that I here Application an Joaquin county ordinancesstate laws,n and that the work will be done in accordance with S , a,and <br /> Fit rules and regulations of the San Joaquin County ' <br /> Home owner ar licensed agent's signature certifies the following:"I certify that In the performance of the work for which this <br /> employ any Person in such manner as to become subject to workman's compensationpermit M issued,E shell nor <br /> certifies the following:"I certify that in the performance of the work for which his laves of California."Contractor's hiring or sub contracting signature <br /> tan laws of Califamis." -pd Permit is issued,I shall employ persons subject to workman's compenaa. <br /> The applicant MUNI call for a inspections.Complete drawing on reverse side. <br /> Signed <br /> Tit(*: i 9 _ <br /> Date: f 4(t•�: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by II 5 9, I <br /> Date f Area <br /> /'rept Grout Inspection by� Data <br /> V Final Inspection b Date i <br /> Additional Commence: <br /> +� Applicant - Return all copies to: San Joaquin county Public Healt4 Services <br /> - Environmental Health Permit/Services <br /> 445 N Sas Joaquin, P O Box 2069, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUNT OUE AMOUNT REMITTED CK O TE <br /> i RECEIVED(IY. PERMIT'N0. <br /> •EM:3-244a IaEY.:ino) <br /> 421 <br /> t EN <br /> ! C/PiOf <br /> 1 <br /> I <br /> I <br /> l 1 <br />