Laserfiche WebLink
Fil APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PRIX EXPIRES 1 YEAR IROM DATE ISSUED <br /> F (Complete in Triplicate) <br /> Application is hereby made,to Sen Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is merle in Compliance with San Joaquin County Ordinance No. 549 and .1862 and the Rules and Regulations of San <br /> I Joaquin County Public Health Services. <br /> 4 <br /> Job Address City 4-11J.DEA-1 Lot Size/Acreage <br /> k Owner's Name R ) C- Id A k- b I Z L 99 Address -37-7-1 AJrZ&Z& S k_Jle,. Phone <br /> Contfactor E44�LP Wd'-IP _Address 7itf,_ADE.L✓3,5i0_T'1_W_4 -—License No. Phone <br /> TYPE OF WELL/PUMP: NEWWELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well Cl <br /> PUMP INSTALLATION ❑ SYSTE EPAIR 0 OTHER p Monitoring WellDISTANCE TO NEAREST, SEPTIC TANK SEWER LINES AISPOSAL FLD. PROP. LINE <br /> FOUNDATION A RICULTU WELL OTHER WELL PITS/SUMPS <br /> E y INTENDED USE TYPE OF WELL AACYON CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom of Well Excavation Dia. of Well Casing <br /> i U Domestic/Private 0 Gravel Pack of Casing SpecificationM Public C1 Other h of Grout Seal Type of GroutCl Irrigalion —.Approx, Depthce Saul Installed by <br /> Repair Work Done U Type of Pump . , State Work Done <br /> FilWell Destruction ❑ Well Diameter .. 3esling lister i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION M DESTRUCTION ED INo septic system permitted if public sewer is <br /> ��'';! ,/ available within 200 feet.) <br /> 6 ' Installation will serve: Residence.! Commercial_. Other <br /> Number of liv..ing_units:.—/—Number of bedrooms - <br /> ��'' Character of soil to a depth of 3 feet: SAN C d- Water table depth <br /> f SEPTIC TANK , Type/Mfg 0- G — jo-y--L- Capacity,)ZrID No. Compartments <br /> PKG. TREATMENT PLT. ❑ y Method of Disposal <br /> Distance to nearest: Well 10,0 Foundetlon Property Line <br /> LEACHING LINE IFNo. & Length of lines —_'�_` �fl _ Total length/size <br /> 12-0 <br /> FILTER BED n Distance to nearest: Well tp9 Foundation� Property Line <br /> SEEPAGE PITS Depth :Xa� Sire G �r Number 3 <br /> SUMPS L1 'Distance to nearest: Well Foundation /OO 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, and <br /> rules and regulations of the Sin 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, t 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 signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's <br /> compensa-tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed Title: Date: <br /> � - FOR DEP RTMENT USE ONLY <br /> Application Accepted by Date "AA Area <br /> Pit or Grout inspection by Date Final Inspection by �� �• Date <br /> k : <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH 86RVICE3 <br /> F, ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201FEE j <br /> I <br /> INFO AMOUNT DUE AMOfUNT REMITTED CASH CK RECEIVED By DATE PERMIT'NO. <br /> IfH 13.21 1REV. i n Sl /I "' 6-6r 5� 7 3093) <br /> fH 1.4,.n <br />