Laserfiche WebLink
C) <br /> APPLICATION FOR PERMIT <br /> a <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-5924 <br /> P O BOX 2049, STOCSTON, CA 95241 FILE COPYo- <br /> YEAR FROM MR ISSUED <br /> (Complete in Triplicate) ; <br /> Application is hereby made.to San Joaquin county for a permit to construct and/or install the work herein described. This <br /> l application to made in comlisnce with Ban Joaquin County Ordinance No, 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services ' <br /> b4/ iP <br /> F Job Address City Lot Size/Acreage <br /> Owner's Name Address -- rn+ Phone �� t <br /> f <br /> Contractor Address License No. �S7'7/ Phoneme ' <br /> TYPE OF WELL/PUMP: NEW WELL Ca WELL REPLACEMENT q RESTRUCTION [7 Out of Service we11 Cl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well ❑ r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 <br /> ' TNTENOED USE-•" '' TYPE OP"WECL •FROBLEIN ARE ',p 15fRUc'TION SPECIF1CA71dNS�" <br /> C7 Industrial ❑ Open Bottom 0 Manteca Die. of Well Excavation Dia. of Well Casing <br /> El Domestic/Private El Gravel Pack O Tracy Type of Casing Specifications <br /> i'1 Public CI Other' n Delta Depth of Grout Seat Type of Grout. <br /> t I Irrioation —.Approx. Depth l i Eastern Surface Seat Installed by <br /> Repair Work Done L] Type of Pump H,P. State Work Done _ <br /> Well Destruction O Well Diameter $esling Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I 'REPAIR/ADOITION Vr DESTRUCTION i I INo septic system permitted if public.sewer is i <br /> d <br /> available within 200 feet.)+^ <br /> Installation wll serve: Residence Commercial ther <br /> Number of living units: --I— 'Y <br /> Number of ro s tf <br /> Character Of soil to a depth of 3 feet: / ��,� Water cable depth <br /> SEPTIC TANK. IW Type/Mfg Capaci%Y /�o 92 _ No. Compartments <br /> PKG. TREATMENT PLT. <br /> L-1 I <br /> Method of Disposal <br /> Distance to nearest: Well Foundation�_�= Property Lina ter <br /> 1 <br /> LEACHING LINE E#`No, & Length of lines <3 r Total length/size O 1 <br /> FILTER BED n Distance to nearest: Wel Foundation _ Property Line <br /> SEEPAGE PITS 10-Depth �� w Size (G � � Number <br /> SUMPS I LI Distance to nearest. Well--Z42 r r <br /> L.�_ Foundation ID r •_,_ Property Line__40 � G <br /> DISPOSAL PONDS ❑ —4 <br /> 1 hereby certify that I have prepared this application and that the work will be d9ne in accordance with-San Joaquin county ordinances, state laws, and <br /> rules and.regulations of the San Joaquin•County• - - _ _.a ; - �y .r i„.r- ' -k <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the-woik-for which this permit"isissued, I shall not <br /> employ any parson 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 perrmit is issued,I shall employ persons subieet.to workman's compen5a• <br /> tion laws of California." t <br /> The appli ant mut cell to all r uir ins I <br /> pections. Complete drawing on reverse side., <br /> Slgned x Tide. <br /> Date: <br /> R DEPARTMENT UsE ONLY" <br /> i <br /> plication Accepted by FO ,. <br /> ` �?Com\ Date+�'�? ` Area ot/l <br /> 01. <br /> grout Inspection,byCL ��3 Date s �,FinalInspection.by. Dat r f <br /> Addltbnal Comments: pi/" 1 <br /> Applicant - Return all-copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hattelton Ave.. P 0 Box 2009. Stockton.: CA 95201 r <br /> s <br /> fSE AMOUNT OVE AMOUNT REMITTED <br /> INFO CASH y�RECEIVED BY `DATE I PPE�RM TTNO. <br /> • EH 19.71(REV.5/>tbl /1. ,/ �V /�'✓�v /"'� V ly /�' p <br /> - EH 11.76 <br />