Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL IiEALTH DIVISION <br /> P O BOX 2009, STOC%TON, CA 95201 <br /> (209) 468-3447 <br /> PEUIT EW-aNS 1 YEAR rRQ9 DATE ISSUED <br /> (Complete in 'T'riplicate) <br /> Application is hereby made.0 Sam Joaquin county for a permit to construct end/or inatall the work herein described. This <br /> application Is wade in coupliance with San Joaquin County Ordinance No. 549 end 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services, <br /> Job Address 535-4 LAS -nPOS,,7ws eleec,_,� City �27e�-J Lot Size/Acreage <br /> Owner'a Name 1_4 W_edzd1CC Address Phone <br /> i <br /> y t p <br /> Contractor FLDYID Ltldtr2? Addressr``7N. ADE�BcPr .Btu License No. "�Z�}'7� Phone �dS 3971 <br /> TYPE OF WELL/PUMP; NEW WELL: �.. WELL.REPLACEMENT F1 DESTRUCTION 0 Out of Service well 0 <br /> PUMP JNSTALLA_TION C SYSTEM REPAIR U OTHER 0 l4onitoring Well- <br /> DISTANCE <br /> ellDISTANCE TO NEAREST: SEPTIC TANK` ~ EWER LINES -Z--DISPOSAL FLp. PROP. UNE <br /> �OLINDATION °a�-V'A !CULTURE WALL `�OTH£i�:WELL P_I7S/SUMPS., <br /> INTENDED USE TYPE OF WELL PROBLEM A -CO RUCTION SPECtfiCAT10NS� <br /> Industrial 0 Open Bottom C Manteca is% of Wali Excavation Dia. of Wait Casing <br /> U Domestic/Private D Gravel Pack ❑Tracy 1, ype of Casing" Specifications <br /> M Pubtic 1"1 Other ` CO De \ De h.ot$rout Seal -'' '` - -7ypa of Grout <br /> r <br /> G IrrQation _.Approxi Depth este n, 3 �Surf$ Soul Installed by <br /> Repair Work Done U Type of Pump H P•^ + Sta4 Work Done_ <br /> Watt Destruction Q Well Diamat Ses-ling,Nateridl Depth. J <br /> Depth - Filler bfiterlal L h �, <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITfON M, DESTRUCTION D (No septic system permitted'if public sewer is y <br /> / l ` available within 200 feet.] <br /> Installation will terve: Residence✓4.Commercialther <br /> �eprY�n7uN%r-y �"' <br /> Number of Going units: _/_ Number of bedrooms 1 <br /> Character of soil to a depth of 3 feet: ei tr �� Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capeciiy No. Compartr rents <br /> PKG. TREATMENT PLT,0 77- Method of Disposal <br /> Distance to nearest: well__4g Foundation Property Line 6, <br /> LEACHING LINE No. & Length of lines a r Total length/size <br /> FILTER BED n Distance to nearest: Welt�— Foundation Property Line <br /> Z / <br /> SEEPAGE PITS Depth X-57_' Size 4 Z�r Number -3 ! / <br /> SUMPS Ll Distaima to nearest: Wem Foundation /l J2 r Property'Line <br /> DISPOSAL PONDS 0 1 f <br /> I hereby canify that t have prepared this applicarion and that the work will be done in accordance with San Joaquin county ordinances,state laws, and <br /> rules and regulations of the San Joaquin bounty , t <br /> Home owner or licensed agent's signature 6rtifies the following: ­J 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 subcontracting signature <br /> certifies the following:"I certify that in the performance Of the work for which this permit is issued, I&hall employ persons subject to workman's compensa- <br /> tion laws of California." : <br /> The applicant must call for all required insplec�uo-ns.l��gmplati`drawing on re <br /> verse side. t <br /> Signed �'CJ �Titfe: (' - �. ! Data: & <br /> } <br /> FO 'DEPARTMENT USE ONLY a <br /> Application Accepted by r�„� ,9, Data Area <br /> - <br /> Pit I <br /> �,�y ,�, <br /> Pat or Grout Inspection by Date Fina!Inspection by J' c-.h"i��,V Date $ f <br /> Additional Comments: <br /> t <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> PNVIRONUBNTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCXTON, CA 95201 <br /> INFO FEE AMOUNT D+IE AMOUNT REMITTED CASH RECErVEppD 8y DATE QPERMIT'�N^O. <br /> • <br /> CH 13-24(REV.irx Df �` l �Z M1� �/��� L J <br /> EH:3•2a +l <br />