Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES PAYWENT <br /> ENVIRONMENTAL HEALTH DIVISION RECEIVED <br /> 445 N SAN JOAQUIN# PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 NWS Z 3 1992 <br /> PERMIT SRPIRSS 1 YEAR FROM DATE ISSUED SAN JOAQUIN CC)UNTY <br /> p;JBL;C HEA,I_Tf- SERVICES <br /> (Complete in Triplicate) JViRONMEN1ALHE4-6iDiVtw;;if. <br /> Application is hereby, made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is aede in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> 3�3Joaquin County PubinicHles.1th Services&Lrr5l) <br /> City Lot Site/Acreage <br /> Owner's Name%\ C Address J(� .� � Phone <br /> Contracla Address. _ (License No.AS7 Phone ' <br /> >a <br /> TYPE OF WELL/PUMP: NEW WELL 71 WELL REPLACEMENT n DESTRUCTION D Out of service veil ❑ <br /> PUMP INSTALLATION ❑ (SYSTEM-REPAIR Monitoring Well OTHER D n <br /> �,_DISTANCETO NEAREST:`SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION �``'"" AGHICULT.URE WELL, w `OTHER WELL �"— PITS/SUMPS - <br /> . <br /> ^!� INTENDED USE TYPE 01: WELL - PROBLEM AREA CONSTRUCTION SPECIFICA710NS <br /> 0 Industrial O Open Bottom O Manteca 'pia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private Cl Gravel P.ck�_D Tracy,.,s :'_ Type of Casing-, _ Specifications <br /> ('1 Publ'F/�,, Cl Other ���(1 Dolts Depth of Grout Seal Type of Grout <br /> I I Imustlon<!;. 1,: _Approxi-Depth I I I Eastern Surface Saul installed byZS <br /> 1' / <br /> Repair Work Duni. U Type f"Pump H.P. State Work Done_ <br /> Well Destruction -4D /Wall Disrneter 414 bio Se+lia6 Nadal'i Depth <br /> Depth f b b Tiller ltlaterial i Depth <br /> TYPE OF SEPTIC WORK:/NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I iNo septic system permitted it public sewer is <br /> •'.LJ /�; available within 200 feet.) <br /> installation will serve: Residents_ Commercial_- Other ' <br /> Number of living units: Number of bedrooms <br /> Character of sol to a depth of 3 fest:' r Water table depth <br /> SEPTIC TANK O TV"/Mfg Capacity-- No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. S Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Wel Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size — Number _. <br /> ..SUMPS_ � �LI Distance to nosrtst:_ Wel. Foun3ation - - Propeny,Line, - <br /> DISPOSAL PONDS ❑ <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 <br /> rules-and reputations of the San Joaquin County i <br /> ..-- Home owner or licensed agent's signature eenifies the following: "I certify that in the performance of the work for which this'perir it is issued, I&h ll not <br /> employ any pet such manner as to become subject to workman's compensation laws of California." Contractor's hiring of sub-contracting signature <br /> certifi0a tee fol <br /> ::'1 certify that in tee p.rformence of the work for which this permit is issued, I shall employ persons subject to workman's compensa• <br /> tion lawn .'rf ?\ l f <br /> The appkca t call for al r=�,WiAnw?6�6` . Complete drawing on reverse side. <br /> Sign" Title: Date: <br /> FOR DEPAATMEN USE ONLY f <br /> Applieauon Accepted by Data <br /> Pit or Grout Inspection by Date Final Inspection by V Det. <br /> s <br /> Additional Comments: <br /> ti <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 448 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE OUNT DUE AMOUNT AEMtTTEOK ECEIV D 0Y ATE <br /> (NFA PERMIT'NO. <br /> . fee 13-24(REV. i ti 11� ✓ _ <br /> EN 14-� •••i� // <br />