Laserfiche WebLink
APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION } <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application IS hereby made to Sao 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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> . <br /> Job Address �/7y�.� /��r•-�eUX /Fes/1 � _ Cot Size/Acreage <br /> ,,Owner's Name � }7� /y!1�rGLz GI 1Y14. bdress �lf r'� Phone <br /> Vit,l� <br /> ✓Contract,& -f� k / ,1_6f Address) ;7&5 Lill:10A ripCLicense No. Z Phone �. <br /> ' 3,i�2_ <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT P DESTRUCTION ❑ Out of Service Well Cl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: S!PTIC TANK maWBR LINA■ GlaPogAL PLO. PROP. LIN! <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I] Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing <br /> (I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing _ Specifications <br /> 1'1 Public f 1 Other 11 Delta Depth of Grout Seal Type of Grout <br /> I 1 Imoation _ Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction C Well Diameter Sealing Material i Depth <br /> Depth Filler Material a Depth (� <br /> INIj1tA1_l­^TI0P9PlQ MerAIMIAtIal InN I I tnktl nuC 1 ING "Pus system Permitted PuMIC "war is <br /> 1 available within 200 feet.) <br /> Installation will"No: Residence_ Commercial X Other <br /> Number of living units: _ Number of bedrooms _ r <br /> Character of and to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg _P N�KC Capacity f'o DC) No. Componments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. 8 Length of lines _ Total length/size <br /> FILTER BED ❑ Distance to nseresC Well F undation Property Line <br /> SEEPAGE PITS 11 Depth SireNumber <br /> SUMPS LI Distance to nearesC Well Foun 'on Property Lina <br /> DISPOSAL PONDS ❑ <br /> t hereby cenify, that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state lawn, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature canities the following: "I cenify that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any person in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or subcontracting signature <br /> cenilies the following: "1 cenify that in the performance of the work for which this permit is issued, I shall employ persona subject to workmen's compenss <br /> tion Ism of California.' <br /> The applicant m_ al for alleapiredyn pecllons. omplet6 drawing on reverse a�iCdgJy y <br /> $�gned � `- Title: �L_I / Date: — t•� <br /> RFKR DEPARTMENT USE ONLY <br /> Application Accepted by 0.. A LAhaAA CMA Date Ata I v <br /> r <br /> Pit or Grout Inspection D Date Final Inspection by Date l <br /> rl It N <br /> Additional Comments: /TZrrC. A12, JVO/ wL {, <br /> APnl irant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, Box 2009, Stkn, CA 95201 <br /> INFO AMOUNT DUE �AMOUNTREMITTEDCASH ECEIVED BY D TE PERMIT'NO. <br /> ftt gsleFV.vseir0v % / <br /> :MH 14 <br />