Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN -COUNTY PUBLIC HEALTH SEkYICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, "CA 95201 <br /> (209) 468-3447 ret <br /> R ?%N DATE IUjJUED <br /> (Complete in Triplicate) <br /> Application is hereby seeds to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in cotpermitlianca.vith Ban Joaquin County Ordinance No. 544 and .1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services . <br /> �l <br /> Job Address City . Lot Size/Acreage . � <br /> Owner's Name, Q��-�1' 1''y`� Address 3 3 GPhone <br /> ner <br /> Contractor �'>F LF Address -.301 'T 4 i e�� .. 'License No. Phonek . I O ab <br /> TYPE OF WELL/PUMP: NEW WELL REPLACEMENT O DESTRUCTION 0 Out of Service Well <br /> PUMP INSTALLATION ❑y SYSTEM REPAIR 0 OTHER O Monitoring Well L� <br /> DISTANCE TO NEAREST: SEPTIC'TASEWER LINES ___, DISPOSAL FLD. ROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WE L PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM ,CONSTRUCTION SPECI EONS <br /> C1 Industrial ❑ Open Bottom 0 Manteca. (Well Er ion Dia..of Weil Casing <br /> U Domestic/Private - 0 Gravel Pack 0 Tracy . . Type Specifications., <br /> 13 Public I71 Oih�.� ,� _Q Delta. epfh of Grout " <br /> Type of Grout (� <br /> Cl lrrigition. Apt 6K.'Depth 0.Easte Surface'Se"41 lnstaileWbv 0 <br /> Repair Work Dons L]. Ty".. Pytttp. H.P. :Slate'Wo a <br /> Wan Destruction 0 Wel Diameter <br /> Sealing Material L Depth <br /> OePth Tiller Material i Depth r <br /> TYPE OF SEPTIC.WORK: NEW INSTALI.ATIONX REPAIR IADDITION-0 .DESTRUCTION C.i- (No septic.system perMitted if public sower is <br /> i available Within 200 feet.) <br /> Installation will"serve: : Residence Commercial_ Other <br /> Number of.Wrl units_: Number p( edraoms <br /> Character of sob to a depth of 3 feet: Water table depth <br /> SEEPTIC TANK. O Typf/Mfg Capacity No. Compartments: <br /> PKG. TfiEATMENT PLT.0Method of Disposal <br /> Distance to nearest: Well oui►dstion Property Line R <br /> LEACHING LINE K_No..b Length of lines --,d - Total Iength/size <br /> op <br /> FILTER BED n Distance to nearest: Well Foundation Property Line , <br /> SEEPAGE PITS -11 Depth Sire Number <br /> SUMP$ U Distance to nearest:. Well Foundation Property tine <br /> DISPOSAL PONDS O <br /> 1 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 /> fulei indrogulations of the Sen Joaquin County <br /> Home owner or licensedligent'a 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?contraeting signetuee <br /> cartifies the following:1.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 Calif orols.", <br /> The applicant mu . 0 all requifod inspections. Complete drawing on reverse side'. C <br /> e'signsd X .."_ <br /> . Title: . Date: <br /> Laa <br /> FOR DEPARTMENT_ USP'ONLY <br /> Application Accepted by .,_; � - Date �� Area <br /> Pit or,Grout Inspection by Date Final.Inspection by Date <br /> Additional Comments: to <br /> Applicant -.Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMiTTED CASH RECEIVED BY DATE PERMIT'NO. <br /> EH ti•i6 <br /> . EM 1.4.29 nEV.,,wsi � ,y• 00 I t 400 m I-3 L4 <br />