Laserfiche WebLink
APPLICATION FOR PERMIT <br /> � T � <br /> SAN JOAQUIN COUNTY .PUBLIC HEALTH SERVICES <br /> ENV I RON1i[ENTAL•. HEALTH DIVISION <br /> Y 1601 E. HAZJELTON AVEC. , 'PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PXRMIT EXPIRES 1 YEAR FROM DATE ,ISSUED <br /> (Complete in Triplicate) <br /> k Application is hereby trade to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> 11[ application is made in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address OQ LVA <br /> City ,� Lot Size/Acreage <br /> Sf Jos�epik N-e"w tf� e% -0rL10, , <br /> f Owner's Name '" <br /> So tis .cr�u►wrat co t^ a fb Pb ox 8 S rhl. . <br /> s <br /> a - <br /> Contractor License No. ,Phone; <br /> TYPE OF-WELL/PUMP: NEW WELL ❑ L. WELL REPLACEMENT ❑ DESTRUCTION'" Out`of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ r OTHER ❑ CS Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ _ f" . <br /> INTENDED USE TYPE OF WELL PROBLEM.AREA CONSTRUCTION SPECIFICATIONS <br /> M industrial []'Open Bottom-----C74Manteca� Dia. of Welt Excavationi <br /> fa Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing pia. of Well Casing t° f�0z Specifications { <br /> 1"I Public Cl Other t n Delta Depth of Grout Seal - ,i r ,\ y] <br /> `` Typo of Grout <br /> ,\ <br /> I Irrigation T,-Approx. Depth .1 1 Eastern ] Surface Seal Installed by `• r <br /> Repair W Type of Pump _ _ "- `1 H-P. St to Work .Done T f 1 <br /> Well traction ❑ Well Diameter = 4�t Sealing Material & Depth <br /> * Depth Filler Material & Depth <br /> YPE OF SEPTIC W NEW INSTALLATION ! I REPAIR/ADDITION I 1 DESTRUCTION I i INo septic system permitted it-public sewer is <br /> I available within 200 f@et.i i. <br /> Installation will serve: Residence_ Commercial__,__ Other ly f <br /> Number of INing units: Number of bedrooms ..� <br /> t r4 <br /> Character ofFsail to a depth of 3 feet: Watertable depth-- <br /> SEPTIC TANK1 ❑ TypefMfg f Capacity No. Compartmants f € > <br /> PKG. TREATMENT PLT. CI / . /fLos <br /> Metho of <br /> I r Distance toV nearest: Well Foundation Property Line fLEACHING LINE C1 No. & Length of linesTotal lengthlsize ` <br /> FILTER BED C7' Distance toynearest: Well Foundation. Property`Line <br /> SEEPAGE PITS III Depth Size `T Number <br /> SUMPS <br /> I Ll Distance toynearest: Well Foundation r Property Line <br /> DISPOSAL PONDS ❑ , I �, ` <br /> tir . <br /> I 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 ei <br /> rules and regulations aquin County <br /> Home owner or ' rased agent's sig tare certifies the following: "I certify that in the performance of the work for which this permit is issued, t shall not <br /> employ any son in such manner a to'become sub' ct t woo s compensation laws of California."Contractor's hiring or sub-contracting sign <br /> atwe <br /> Certifies th ollDwin0: "I t erti}y the the perfor h or or which this permit is issued, I shall employ persons subject to workman's cvmpensa <br /> tion taw of Cal;fornla.' E I <br /> The app'cant mu uired ec drawl g on r ide. <br /> Signed X i.... 1 e: ,_ .- <br /> - Data: _ <br /> �Uk�FAIITM�1111T �011L <br /> Y <br /> ]plication Accepted by , <br /> A - - Q Date �o g "9 O Area <br /> Pit or Grout Inspection by ' Date Final Inspection by Date g 3 LO <br /> Additional Comments: ( ' <br /> Applicant - Return all copies to: rSan Joaquin County Public Health <br /> 'Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> .'e <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO ASH RECEIVED BY DATE PERMIT'NO. <br /> . Eli 1324 IREY.I/AS) <br /> EH @x.26 ��o D 6 �`. <br />