Laserfiche WebLink
APPLICATION FOR PERMIT <br /> aEA-LTH SER <br /> SAN JO 'j5IN COUNTY PUBL�1 TH DIVISION V sS <br /> AQ <br /> ENVIRONMENTAL HEAL' <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON , CA 95201 <br /> E I E�IRE1ete S I YnATrFipOlicate) L <br /> IS� — <br /> (Comp <br /> onstruct and/or install the work herein described. This <br /> Application is hereby <br /> made to San Joaquin County for a permit to c <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Rcgulationa of an <br /> Joaquin County Public Health Services. �f Lot Size/Acreage <br /> r7 /l�E.�tJ� itv <br /> Job Addressl./ 5Ai6l fz2rf l 1 rCi "M 41'Vell G < /�-7_6 <br /> 5 Phone S�U �7 G O�S s <br /> �n �U.Y ✓vv <br /> C ✓��� Address <br /> Owner's Name /r !!� ,! �26 _Phon- <br /> Sy70-7 <br /> �� License No. <br /> S��S Address DESTRUCTION O Out of Service Well ❑ <br /> Contractor. WELL REPLACEMENT i: Monitoring Well Q <br /> NEW WELL OTHER a �Zv <br /> TYPE OF WELL/PUMP' - SYSTEM REPAIR 2 �(/� PROP LINE <br /> PUMP INSTALLATION N�- DISPOSAL FLO.�— <br /> IVAI SEWER LINES ------ PITS/SUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE 'NELL OTHER `HELL <br /> FOUNDATION �' <br /> ENDED USE TYPE OF WELL PROBL�AREA CONSTRUCTION SPECIFICATIONS Oia. of Well Casing <br /> ❑ Manteca Dia. of Well Excavation, JQrrr40�Uzp'b:/a t+' <br /> I et�/Ncr,i iR(/❑ Open Bottom �n,,(E y0 O�'lc' Specificd[.ons <br /> ❑ Tracy Type of Casing � 9>1•1.i�L��;r <br /> ❑ Gravel Pack i T it/G K Type of Grout <br /> CJ Domestics Private /� (I Delta Depth of Grout Seal <br /> I Public j;f Other (� <br /> Surface Seal Installed by <br /> I IrnOation lAPProx. Depth 1 I Eastern State Work Done _ <br /> Type of Pump H'P' <br /> L Repair Work Done ❑ Sealing Material Depth iAT/h/X2��"ii 3-Sia �ri <br /> Z/�Nell Diameter -- th�7�/t 7,f�^/JCF�f <br /> Well Destruction Filler Material i Dep <br /> Depth <br /> c system <br /> Is 411 <br /> Sep <br /> TYPE OF SEPTIC WORK: <br /> NEW INSTALLATION i, I REPAIR/A001TION I DESTRUCTION I I availablerwthin 200 feet.) f public sewer <br /> Commercial _ Other <br /> Installation will serve: Residence C'� <br /> Number of living units: <br /> Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: Capacity__-- No. Compartments <br /> , <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal cul ul <br /> PKG. TREATMENT PLT. ❑ Foundation Property Line _--- <br /> Distance to nearest: Well <br /> Total lengthisize <br /> LEACHING LINE 0 No. & Length of lines Foundation <br /> FILTER BED Property Line <br /> ❑ Distance to nearest: Well <br /> Number <br /> SEEPAGE PITS 11 Depth Size Property Line — <br /> SUMPS LI Distance to nearest: Foundation <br /> Well — <br /> and <br /> DISPOSAL PONDS Cl <br /> h San <br /> I shall not <br /> I Hereby certify that I have prepared this application and that the work will be done in accordancCe oftthe work for Joaquin <br /> this permitcssssued laws, <br /> rules and regulations of the San Joaquin Cour Y g rf0(man <br /> Home owner or licensed agent's signature certifies the to workman's <br /> 'I certify that in the Pe I persons h subject to workman's compensa <br /> employ any person in such manner as to become subject <br /> tothe workator wh chethis permit v s issued, I shalt emp oyap rso sting c sub-contracting workman <br /> sg mpe signature <br /> certifies the following: ''I certify that in the performance <br /> bon laws of California." <br /> i inspections. Complete drawing on reverse side./ /� i <br /> The applicant must call to II Date: <br /> Title: �f <br /> Signed �T <br /> FOR DEPARTMENT USE ONLY i t� <br /> � I Area <br /> Date <br /> by <br /> Application Accepted Date�— <br /> Date Final Inspection by <br /> Pit or Grout Inspection by <br /> Additional Comments: public Health <br /> Applicant - Return e11 copies to: San Joaquin County V <br /> Services, Eavironmental Health Permit/Service, <br /> P 0 Sox 2009 tockton, CA 95201 <br /> 1601 E. Hazelton Ave•. PERMIT NO. <br /> CK R EIVED By GATE <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO -NO <br /> `EM 13-24IREV.I/as) !., <br />