Laserfiche WebLink
a <br /> r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O. BOX 2009, STOCKTON, CA 95201 <br /> .PERMIT EXPIRES 1 YEAR FROM DATE <br /> (Complete in Triplicate) <br /> f Applicafion is hereby tmde•to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> Ile application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address f t69kx-VZgk1 City Lot Size/Acreage <br /> �- Cl1 Aa � �A� IC Phone 4 <br /> Owner's Name .�/1f <br /> F Contractor K r' 1U J�� ddresslc G'� License No. �� Phone <br /> TYPE Of WELL/PUMP: NEW WELL' WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR 0 OTHER 0 Monitoring (11 E3 <br /> DISTANCE TO NEAREST: SEPTIC TANK "¢ SEWER_LINES_ ,DISPOSAL FLO. ` -- PROP.`_LINE <br /> FOUNDATION AGRICULTURE WELL ` ``V OTHER�WEL`O' 7—""�PIT578LJMP5 �Q, <br /> 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS A <br /> El Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> xDomestic/Private -AirGravei Pack7 E7 Tracy Type of Casing_.._- _ A910fr— __ Specifications <br /> I'1 Public i-1 Other F1 Delta Depth of Grout Seal fry'0 <br /> Type of Grout a <br /> I I Irrigation �.Approx. Depth .l 1 EasternSuflace Seal Installed by <br /> Repair Work Done ❑ Type at Pump .- H.P. Stats Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material A Depth ` <br /> Depth Filler Material i Depth ` n <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I 1 INo,septic system permitted it public sewer is 14vt� <br /> i 'avaiiabW.within 200 lest.I <br /> Installation will serve: Residence— Commercial— Other 4 �; <br /> Number of living units: Number of bedrooms <br /> Character of$od to a depth of 3 feet: <br /> Water table depth <br /> SEPTIC TANK. _ <br /> ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ t _iAethod'•of-Disposal , <br /> Distance to nearest: . -Well Foundation Property Line <br /> LEACHING LINE Ll No. i Length of lines Total length/size y : <br /> FILTER BED 0 Distance to nearest: Well Foundation Property_Lins_- <br /> SEEPAGE PITS 11 Depth Size _.._ .Number. r <br /> SUMPS LI Distance to nearest: `` Well Foundation Property Line <br /> DISPOSAL PONDS ❑ r, <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, an 1 <br /> rules and ragulations of the San Joaquin county ,� , <br /> Home owner or licensed agent's signature certifies the following; "I'crtify that in the performance of the work for which this permit is issued,.)shall not <br /> employ any person in such manner as to become subject to workmen's compensation laws of California."Contractor's hiring or sub•confracting$16ilisture <br /> certifies 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 California." / I <br /> The applicant t ralf requir tions. Complete drawing on revy" <br /> Signed Title .�'�X ~e Data: <br /> F DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date Area <br /> --1:71 <br /> _ I <br /> Pit or Grout Inspection by Date t: 1 " Final Inspect' byData 1U <br /> Additional Com <br /> menq: k �_,— r j . 0.1,.,, .�.�,�...�--_, — -Wit,.r - ;.� :.�,,�. '• . <br /> Applicant - Return all copies• o: San Joaquin County Public Health Services <br /> 'Sri 445 <br /> Health.Permit/Services <br /> ;.445 N�SanJoaquin, -P O.Box 2009., Stkn, CA 95201 <br /> #FE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> . EN IX241BEV.i fori <br />