Laserfiche WebLink
APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HET IARV�S Q-aCQ 73 <br /> ENVIRONMENTAL HEALTH D <br /> 445 N SAN JOAQUIN, PHONE (209➢�6 3420 <br /> P O BOX 2009, STOCg'PON, AAg5p1 <br /> PERMIT EXPIRES 1 YEAR FROMIDATESSU <br /> (Complete in Tripli s <br /> 4-z& <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install t e e his <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of an <br /> Joaquin County Public Health Services. (� ( ! <br /> Job Address 70 �9 F KL 1 <br /> Y � City JC'�t�A Lot Size/Acreage �[d <br /> Owner's Name 4,-f'4,1 U(,ny `rem I Address 54;,7NC. — Phone 3 �T a 1 <br /> IM l <br /> Contractor Y11IC e � � <br /> t � Address (1 <br /> te0Y 00 License No.Ua Es_-Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of-Service-Nell- ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> j FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> n Domestic/Private, Cl Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ('1 Public I-1 Other F1 Delta Depth of Grout Seal Type of Grout <br /> 11 Irrigation —Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done; C3�\ Type of Pump H.P. State Work Done,_ <br /> Well Destruction i E3Well Diameter Sealing Material 14 Depth <br /> I Depth Filler Material Z Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> f available within 200 feet.) <br /> Installation will serve:, Residence, Commercial_ Other <br /> Number of living units: t Number of bedrooms <br /> Character of soil to a depth of 3 feet:. 't"~ G Water table depth <br /> SEPTIC TANK. 0' Type/Mfg P✓#7- Capacity � -�h No. Compartments <br /> PKG. TREATMENT PLT. ❑ ) . Method of Dispo#al <br /> Distance to nearest: Wellf Foundation tS Property Line _ <br /> LEACHING LINE No. & Length of lines ".y �.+� dotal length/size <br /> FILTER BED ❑ Distance to nearest: well: I�2�ation f Property Line { <br /> SEEPAGE PITS f_ 11 Depth T LO Size' f X 1() ,��tNumber <br /> SUMPS Distance to nearest � .,.� <br /> Well Foundation_y_� Property Line <br /> DISPOSAL PONDS <br /> I hereby certify that I have-prepared this application and that the woj•k will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County i <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 signature <br /> certifies the lollpwing: "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 c I for all Aukedd inspections. Complete drawing on reverse side. <br /> Signed X Title: �(,a&t Date: <br /> R D7,M=tS <br /> E-0AILY X�( <br /> Application Accepted by Date Ar d�v <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments: <br /> ~ Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 1 _ ,� � 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> ft'a�]' EEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br />